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Please riot or <br />p type. (Form designed for use on elite (12 -pitch pewriter.) <br />DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />oan p roved. MB No. 2050-0088 <br />4. Mariffest Tracking Number <br />WASTE MANIFEST <br />�,� L a 0J � i 8) .' j <br />' <br />afro-�2 i f130fi CtiEf Tf tEC <br />Q 04 8 <br />1 L441 JJK <br />5. Genre ame aodrtailing Address Generator's Site Address (if different than mailing address) <br />Generators Phone: C 2.� I ~ C'5 - <br />6. Transporter 1 Company Name FREM OM ENVIRONMUITAL SERVICES INC t• M0 t0! t 00-559-32,,, 4 U.S. EPA ID Number C:AROOO 17 1017 <br />7. Transporter 2 Company NameU.S. EPA 10 Number <br />^1 V CENTURY ENVIR01WENTAA h1,'id•fAUEAr1ENT OF NEVADA. LLC CNROTF.)1(41012 <br />8. Designated Facility Name and Site Address 2'1 ST CENTURY EMI U.S. EPA ID Number <br />2085 Nr-.Wt.ANn-6 DRIVE, EASE 1n+Ony3(1t1�r5titfl <br />FERNLEY, AIV 89408 <br />77S-575-2-160 <br />Facility's Phone: <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt./Vol <br />13. Waste Codes <br />No. <br />Type <br />1. (ulty <br />LOW <br />0 <br />W <br />2. i. r., �Jr^.�t_T r'y+y.� ��:, d`A<* <br />O <br />l 64 jz� r i t) .7 (, r G J ('i. K^ 7_-i j�l �`I Z <br />1 <br />Ll 5 <br />P <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />Hurdlers to be 40ttr ir:riried and ! Inc+ PPE <br />9b 1) 3801(3)t3 -Ott I ti; F R r3 0 1 7 i <br />15. OENERATOR110FFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 26227(8) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generator pfferors nledfTypod Name Si attire Month Day Year <br />-J <br />Z <br />16. Intemational Shipments <br />❑ Import to U.S. ❑ Export from U.S., Port of entrylexit: <br />- <br />Transporter signature (for exports only): Date leaving U.S.: <br />U <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 PrintedrTyped Narrjp S g4ature Month Day Year <br />rn <br />' <br />7d.. <br />Transporter 2 PrintedlTyped Name i Slgdature Month Day Year <br />i <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br />Manifest Reference Number. <br />18b. Altemate Facility (or Generator) U.S. EPA ID Number <br />J <br />v <br />ua. <br />Facility's Phone: <br />LLj <br />16c. Signature of Alternate Facility (or Generator) <br />Month Day rear <br />Q <br />Z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />UJ C3 <br />1. <br />2. <br />3 <br />4. <br />20. Designated Facility Owner or Operetoc Certification of receipt of hazardous materials covered by the manifest except as noted in Ilem 18a <br />Printed[Typed Name 7- Signature Month Day Year <br />1 <br />l .c,.l,�. -. r <br />DESIGNATED FACILITY TO GENERATOR <br />