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351326 1212675 <br /> ` Please print ortype.(Form designed forum on aide(12-pitch)type taitec) Farm Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.temerator lD Number 2-Page of B.Emergency Response Phone 4.Manifd rjgNumber <br /> WASTE MANIFEST CANII1000503 2 (877) 577-266 0 0 2 7 0 8 798 FLE <br /> 5.Generator's Name and MalingAddress Genemft fs Site Address(if d'Arerent than mailing address) <br /> SAI 30RIUIN Own PUILIC OORKS *PRRTNENT SRR AUDI COUNTY PUILIC Ill 1EMT ENT <br /> 1111 EAST WELTON AVON 17721 E. WOO Luff <br /> Genaata9010N CA 95211 (219)(51-1955 L011 CA 95741 (219)411-3115 <br /> .Tansponerl Company Name U.S.EPA ID Number <br /> 21st CENTURY ENVIRONMENTAL MANAGEMENT OF NEVADA, LLC CAR000164012 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility NamearM1de Address S p/f 7Jy /L U.$,EPA ID Number <br /> z 1.4+8 306 <br /> �415Fa1EFFERBEIC'IOf� yBS�b/d•,4-•i�ObEPILO/�D sT• �..,_/ Cq.(¢ /l7oodOSF� <br /> Faall Phone: :504 / /�q,l TSG 888988884 f$ <br /> 9a, 9b.U.S.DOT Description(refueling Proper Shipping Name,Hazard Class.ID Number. 10,Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if anyp rye. Type Ouanety WINol. <br /> L <br /> Qo X CF P <br /> up <br /> X S l� 'J� DM P <br /> 3 UNIVERSAL INISTE LM <br /> `! J <br /> X �'/� / �J, CF `� P <br /> jtl <br /> -v+ <br /> 14.Special Handling Instructors and Add'Naal Informal <br /> (1) S3C111M11-11 - ERS1171) RSIESTOS, LAMIFILL (7) SJM351-11 ERC(127) LOOSEPRCI OIL LASE P (3) SX M I15-11 <br /> FLUORESCEIIf TOIES, 1 (4) SX M1921-11 ERS(171) PCI LISHT 1ALL S,ALL IASTE IS EIRNPT.MUSEH(U IIIIARIOUS PASTE PEI <br /> 419R251.4b. i <br /> 15. GENERATOR'SIOFFEROR'SCFRTIFICATION: Ihereby declare that tier contents of this consignment as fayand amuateyrn'hbove <br /> desed abylhe proper shipping name,and ere classified,packaged, <br /> marked and labeled(pmcaded,and the In all respects in proper condition for transport according to appgm6le international and national governmental regulations.H export shipment and l am the Primary _ <br /> Exporter,Icertify that the contents of this consignment coform tote ferns of to attached EPAAcklumledgmemofConsent. <br /> I certify Nat the waste mmunizaton statement identified in 40 CFR 26227(a)(if I am a large quanttygenerator)or(b)(dI am a small quantity generates)is We, <br /> f emfs nn yyed Namewin ay ear l 141 <br /> ('r a <br /> F 6.Inflisrutional Shipments ❑Import to U.S. ❑Expo S. Pod ofmWedt <br /> Tan rtar si nature for only): Date leal U.S.: <br /> w 17.TrransporlerAclmnMeagmmt of Receipt ofMateuds <br /> Ta porter1 Printed!( Nye <br /> re y ear <br /> N <br /> o a <br /> Transpader2 7rusesilypead Name ig re ay year <br /> aF' <br /> r18.Discrepancy <br /> 18a Discrepancy Indication Spam ❑ Growl ❑Type ❑Residue ❑Partial Reduction El Full Rejector <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(a Generator) _ U.S.EPA ID Number <br /> J <br /> U <br /> Q <br /> LL Fade sPhore: <br /> w 19e,Signature of Alternate Fal(a Generator) Monne Dap You <br /> a � I <br /> z <br /> S2 19,Haardous Waste Report Management Method Codes(i.e.,codes for mora us waste annual disposal,and recycling systems) <br /> C 1. 2. 3. 4. <br /> Y <br /> 1 20.Designated Facility Owner or Operator.Ce fifi <br /> 'pl of hazardous mahrca6 mveretl by the man' as noted in Ilam 18a <br /> P'nferUf Na ria res pay Y f j <br /> N �• LnChJe <br /> EPA Form 8700-22(Rev.3-0 ) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> i <br />