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Please print orr pe. (Form designed for use on elite 02 -pitch) Noewnter.I <br />MIC., 01928.1 3u <br />• From Annroved. OMB No. 2050-0039 <br />CYA t0ill 1511111 tenser. "o7,Crevlous anions are oosatets. <br />�/ � 11146.1379 <br />iDESIG`r7 FACILITY TO GENERATOR STATE (IF REQUIRED) <br />UNIFORMHrRDOUS <br />1. Genemlar lD Number <br />2. Pagel of: <br />3. Emergency Response Phone 4. Manifest Tracking Number <br />3 JJ K <br />WASTE.MANIFEST <br />I999 <br />0 0 �6 0 <br />6. Generatols Name and Mailing Address^'Ali 414 !41;9�a Gene7moes&fe ressnddrre nm ailing address) <br />J & C Aho Motor <br />1830 N. Witsora Way <br />StoMon, CA 85209 <br />Gene2lols Phone' <br />gilgii <br />6. Transporter 1 LOm�a N me U.S. FPA ID Number <br />Freirri Fnr4mryl-P rx Irtc 79 <br />7. Transporter 2 Company Name U.S. FPA ID Number <br />Im"lifinm'I D n <br />—FW <br />8. Designated Facility Name and Site Address U.S. EPAID Number <br />US Eico!ogy <br />H'A•y 9511 Wes S of CY 18 acres NM30010000 <br />Beatty, NV 89003 ' <br />Facility's Phone: ' <br />ga. <br />9b.. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers11. <br />TOW <br />12. Unit <br />13. Waste Codes <br />No. <br />Typo <br />HM <br />adPacking Gmup(ifanyp <br />Dustily, <br />x191 <br />1. <br />0 <br />Norr-RCRA Hazardous Waste, Sol (Brake Shadings) <br />I <br />&M <br />�® <br />P <br />z <br />Z. <br />W <br />3.- <br />4. <br />10. Special Handling instructions and Additional Inmanaton <br />8b.1) Brake Starvinas - ERG ir 171 <br />Hahr9ers to be 40hr trained end Wear Proper PPE f X S 1>F <br />15: GENERATOR'SrOFFEROR'S CERTIFlCATION: I hereby declare that the contents of this consignment am fully and accurately described above by the proper shipping name, artlarecIassified,Parhaged.; <br />marked and labeledlplaarded, and are in all respects in proper condition for transport according to applicable international and national govemmental regulations, If export shipment and I am the Primary <br />Exposer, I cagy that the contents of this consignment =turn to the lams of the abashed EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement r(en56ed in 40 CFR . la)'(d I am a large quantity generator) or (b) (dl am a small quantity generator) is true. <br />Generators/ mi'sAn yped Name SignaNre , /J iMonth Day Year <br />(/ �� <br />'.. H- <br />.'.. -❑E_pd=mU1--P_ <br />Transposer signature fore its only): 9 ( xpo alk Dateieavirg U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transports dRyyed Name Signature Month Day Year <br />cep <br />N <br />Q <br />TransporterPsnl <br />came SignaNre <br />iMonth Day Year <br />1 J U -err <br />. .rap o. 106 1 /z - <br />Z18. <br />18.Discrepancy 1 I <br />r <br />18a. Discrepancy IndiaVon Space ❑ Ovanti y Type Residue Mue ❑Pa1rtial Rejection ❑Full Re etion <br />Man ted Reference Number. <br />1 all. Ntemate Facility (or Genesi EPA <br />J <br />U.S. ID Number <br />U <br />LL <br />Facrlilys Phone: <br />w <br />Ise. Signature ofAltesnate Facility (or Generator) <br />,Month Day Year <br />a <br />z <br />h/ <br />19. Harardaus Waste Report Management Method Codes (i.e., odea for hazardous wasteposta rat, disposal, and recycling systems) <br />2. <br />20. Designated Fadiiy Owreror Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item Its <br />1 <br />PnntedRyped Name Signature .Month Day Year <br />DI <br />CYA t0ill 1511111 tenser. "o7,Crevlous anions are oosatets. <br />�/ � 11146.1379 <br />iDESIG`r7 FACILITY TO GENERATOR STATE (IF REQUIRED) <br />