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MCD <br /> Please print o,,type.(c=orm designed for use on elite(12,pkoh)typewriter.) Form Approved.Ol No 2050-0039 <br /> 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4. ni t rackl Number- 645 <br /> UNIFORM HAZARDOUS 1 0� + FLE <br /> WASTE MANIFEST <br /> 5.Goneratoes Name and Malting Address Generators 5 is Address(if di anent than mailing address) <br /> Pacific Southwest Container <br /> 435:3 E. Fremont Street <br /> Stockton CA 95215 <br /> Generators Phbna. <br /> 6. ransporter 1 Company acme U.S.EPA ID Number <br /> Advanced Chemical Transport Inc. (SV) <br /> CAR� <br /> T Transporter 2 Company Mime U.S.EPA 10 Number <br /> 8 Designated Facility Name and Site Address Is S.EPA 10 Number <br /> US ECOIo�y Nevada Inc NVT33001�0 <br /> PO BOX 578 11 Miles S Beatty <br /> Beatty, W 69W3 <br /> Facllity's Phone' 775:53,2203 <br /> 9a 9b,U.S,DOT Description(including Proper Shipping Name,hazard Gass,ID Number, 10,Containers 11,Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(If any)) No. Type Quantity WI.lUvt. <br /> ie Corrosive li Wd ha <br /> oX` (nodi drate),8, <br /> PGA 122 <br /> d basic,inorganic,fr.o.s. <br /> (- •odium metasdicate peat rydrate), <br /> PGn <br /> i(.,w p q k Hair.fres ,fit , slrrr'sfl ` � 1 2.� 3$Z <br /> 1�Yl�yL CCar9-T.3�-��, <br /> 4 <br /> 14,Spada Handling Instructions and Additlonal Information Pmja t(,umber 144083 Dwilument D172831 <br /> 2)EIZi#lSS; e7e1�T71(I.{Z31.�ael I_ <br /> 19. GENERATOR'S10FFEROR'S CERTIFICATION: I hereby declare thatthe contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,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 certify that the waste minimization statement Identified In 40 CFR 262.27(a)(If I am a large quentily generator)or(b)(if I am a small quantity generator)is true. <br /> Horace s er sme ypad gha ure Von1h ay ear <br /> e'a 4 o K 03 - <br /> j16.Inieunaiionat Shipments ❑Import to U.S. ❑Export from U.S. Port of entrylexit: _ _ — <br /> z Transporter signature for expods only) Date leaviN U.S <br /> 17.Transporter Admowledgment of Receipt of Materials <br /> Transporter rnIe ype oma Signature ant ay ear <br /> O <br /> WMonin ay ear <br /> Transporter 2 Priniedflyped Narne Signature <br /> 1 I <br /> 18.Dascrepanuy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type R%Idue ❑?adial Rejection ❑F0 Reiecl on <br /> Manifest Reference Number: <br /> 1 Bb.Alternate Facility(or Generator) 10 Number <br /> J �r <br /> V <br /> Q <br /> FaCili s PhUne'. <br /> w 18c.SlgnatureofAltematsFactAy or nerator AL HLAITH Month Day Year <br /> a <br /> Z <br /> 05 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1 2. <br /> 20,Designated Facllity Owner or Operator:CergTicall of recei of hazardous materials covered by the manifest a sept as noted in Item 16a <br /> PrinledlTyped Name 6igna[ure month Day Year <br /> hm�m 11 11 �A 113 <br /> EPA Form 6700.22(Rev. 5) Previous edition olsalete. �,W.11LITY TO DESTINATION ST (IFR OUl 1 <br />