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case print or type. (Form designed forum on elite (12 -pitch) ty)exaitec) <br />UNIFORM HAZARDOUS 1 1. Generator ID Number 2. Pa <br />WASTE MANIFEST CIV ti81R 7'7),.0 <br />5. Genera&s Name and Haling Addrees <br />i:;0%N.KJCIA,)IN RF(.W.lWI iftAm fl <br />P t) fW)X 2011)10 <br />Gerava ,Phone: Z1Pl tic -raj. <br />6. Transpabr 1 Company Names <br />,,WERIC:W VALIAY :rA!- It !.rll INC; <br />0 <br />,:U14 -99+s 5bW <br />I'r73 LNiNS:AY <br />16AV, <br />U.S. EPA <br />Form Approved. OMB No. 2050-0039 <br />ng Number <br />353301 GBF <br />CAM."J8.:878 <br />�13t CENTURY LWHi;M11Y1E%IAL M,3MI Of NI -VADA LL(: tNf7viV]aU53'18 <br />NLWtAM),i L)N FA::1 <br />I-LPrM.tY, NN 61r4(•n <br />F Phesns' /i" .... 7kY1 <br />9es. 9L U.S. Darn I Iwt (Ildutir I Proper Shipping Name. Hazard Class, 10 Number. 10. Canhmen 11. Tata) 1T. Unit <br />HM arNPa6tip�YPes <br />4(RaV) N..T om. 13. West Coda <br />1. <br />Ni)PFKCW1tV4lAitUU1J;i WA:,Ik LlOUiU Iri k; <br />t HHIFIF ANIIFRF.FZE X)LUTKdJt Asti <br />PR(Ji Ilk Y 3: 044 OV <br />15. GENENATON'SIOFFERON'S CERTIFICATION: I hereby declare Mal the conlerM of On consignriMm are fully and accurately desmead above by Me proper shipping fines, and are classified. Padul*. <br />marked and labs scilplacerded. and are in all rebPBrS51n proper oarkdNM for transport according ta applicable inlemabonal and national govemmentel regNaCoa. n export shprtient and I am ane Pnrnary <br />Espester. I grey that Me am" of MIO mnsignrent conform to her terra U the adached EPA AgknaNed rent of Consort. <br />I certify Mal Me waste mnimvaem shtemerr identified in 40 CFR 262.27(a) (if I am a large quantity genensor) or (b) (if I am a snag quantity generator) h ba. <br />.. Ll Import ia U.S. Ll Espen from U.S. Pat ofer"ied <br />Transporter signature (for exlporh any): Data leaving US.: <br />17. TwVw*MlknoMedgrrend of Recept of A/amnals of <br />18. Discrepancy <br />1Ba Diurepancy Indra6m Spaces ❑ Ou'diy ❑ Type <br />Ph": <br />❑ Residue <br />❑ Partin Refection ❑ Ful Rejectlon <br />19. Hazardous Waste Repod Management McMod Codes (i.e., codes for hazard" waste treatnenl. disposal, and recycling systems) I <br />20. Designated Fad ity Owner es Operates: Certification of receipt of hazardous materials covered b <br />PdnteMyped Name <br />are oosaete. LL <br />as Toned in Item 18a Notice: State of California requires <br />generator to photocopy and mail to <br />DTSC within 30 days: <br />P.O Box 400 Sacramento,Ca 95812- <br />0400 <br />