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Please print or type.(Form designed for use on elite(12-pitch)' p Vriter) Form Approved.OMB No.2Q50 0039 <br /> UNIFORM <br /> HAZARDOUS I' Generator ID Number 2. . 1 of 3.Emergency Response Phone 4..Manifest Tracking Number <br /> WASTE MANIFEST CAL"318774 1 W-0-424- E 0040- 39761 JJ K <br /> 5.Generator's Name and Mailing Address Generator's Site Address(d different than mailing address) <br /> CENTRAL SPRING,JNC <br /> 1q1�E�78taVC3 Y+lAY <br /> ''TOCKTON.CA "206 <br /> Generatnr5 Phone. c <br /> 5.Transporter 1 Company Name <br /> US.EPA ID Number <br /> FIR:EM 3tAN EtohllRt)WENTAL SEFiME S N IC Rwm 0 aW 0-3,274 CAROW 1710 t 1 <br /> 7.Transporter 2 Company Name U.S.FSA Ip Number <br /> 21ST CENTURY E.Afll CARUC164)1m <br /> B.Designated F llty Name and Site Address P U.S_EPA ID Number <br /> 21ST MI#'TJRYrll tdV f 1F11lL'ir3Ei. 3ti <br /> 2W6 WWLA"DRIVE,tNber' <br /> ST <br /> FERNLEY,NV 89408 <br /> Facilit es Phone: 7 _ <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,HazdW Class,ID1e.Containers 11 Total 12.Unit <br /> HM and Packing Group(it any)) 13.Waste Codes <br /> No. Typo Quantity Wt.Nol <br /> f <br /> © 1 kart-RCFtA Flazxdcxm VVa'46 Soil(F-dtar Cakesi UM P 1151 i <br /> Z 2. <br /> 3. <br /> 4. <br /> I <br /> i <br /> 14.Special Hanoting Instructions and Additona)Information <br /> I V411LEKS T 1 BE 40M TRAINED AND WEAR PPE. <br /> 98 1) 3at3249-00 ERGO 171 <br /> 15. GENERATOR'SIOFFEROR'S GERTIRCATION: I hereby declare that the contents of this consignment are fully and accuraWy described above by the proper shipping name,and are classified,packaged, <br /> marked and%belediflilacarded,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 EPAAcknowledgment of Consent. <br /> I cerlify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true, <br /> Generata'"erors Printed/Typed Name Signature Month Day YRAC <br /> r <br /> .-j 16 International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entrylexd: <br /> z Transporter signature(for exports ony), Date leaving U.S.: <br /> L 17.Transpo terAdmowledgrnent of Receipt of Materials <br /> T r 1 Printedi7yped ray D Year <br /> O 't <br /> ZQ Transporter 2 Printed'Typed Name NgMture - Month Day Year <br /> M <br /> 18.Discrepancy <br /> 1 Ba.Discrepancy Iced cation Space ❑ puantty ❑Type ❑Residue ❑Partial Rejectiam ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Faaliiys Phone: <br /> w 18c.Signature of Alternate Faciiily(or Generator) Month Day Year <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Q t. 2- 7-- <br /> 4 <br /> 20.Desgnated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedfryped Name Signature Morin Day Year <br /> EPA Forrn8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />