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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4,Manifest Tracking Number <br /> WASTE MANIFEST CAC002655825 1 866-333-9222 j0034.47141 FLE <br /> S.Generator's Name and Ma ling Adjr—as's Generators Site Address(if different than mailing address) <br /> Frank BRor.i.ta 824 E Chaster Way <br /> 6622 belmonte Pl Staa]+an, CA 515206 <br /> StocPton, CA 95207 <br /> Generators Phone: 900 418—"46 <br /> 8.Transporter 1 Company Name U.S.EPA ID Number <br /> Advanced Chemical Transport CARO00070540 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Desi Hated Facitity Name and Site Address U.S.EPA ID Number <br /> II Ecology Nevada, Inc. <br /> P.0 Don 578, Hwy 95, 11 pules S_ Beatty <br /> Beatty, NV 89003 <br /> Facilitys Phone: 800-239-3943 BY 30010000 <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity WL/Vol. 13,Waste Cedes <br /> Cr 1. NA3077, Hazardous waste Solid, N_O.S. (bead) B00 611j <br /> I <br /> 2. I <br /> 0 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 1) �"�77C717 7� 0 <br /> Pxoject Humber-- 0903.363 <br /> 15. GENERATOR'SIOFFEROR'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 ail respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,!certify that the contents of this consignment conform to the terns of the attached EPAAcknowiedgment of Consent. <br /> I certify 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 /> Genera s/Offeror's Pr,irrJnted/Typed Name cna use on ay ear <br /> Z a 1`11 t ti/ " �l �I.f'i ( 2© l C <br /> ...r 16.International Shipment <br /> i— ❑Import to U.S. ❑Export from U.S. ort of entrytexit: <br /> Transporter signature for exports onl l: Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transpr rter 1 riniedfTypedNamriMonth Day Year <br /> 0. 1 `��r� a tea... 10%101 iU <br /> Q Transporter 2 PrintedlTyped Name Signature Month Day Year <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy indication Space ❑ Quantity ❑Type Residue !' <br /> ❑ ❑Partici Re;aCSon FL�1I Re',,Gion <br /> Manifest Referents Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> U- PaaRi's Phone: <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> th <br /> G7 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU t. 2. 4. <br /> 3a <br /> 20,Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedfTyped Name Signature / Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. / DESIGNATED ACILITY TO DESTINATION STATE(IF REQUIRED) <br />