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a Form AnDroved. OMB No. 2050-0039 <br />EPf Fr7,Q0-n _ 4 <br />Rey. 3-05) Previous eartions are oosoieie. <br />4 <br />ef,)61 91 3'-5,28/ 40 1014011 <br />JZ31 R 9 104 _\iI'll, 11 <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response <br />; <br />Manifest Tracking NumberCAD9- <br />UNIFORM HAZARDOUS 11�64489 <br />SKS- <br />WASTE MANIFEST <br />1-400-46a <br />:657 <br />5. Generator's Name and Mailing Address Generators site Address (if different than mailing address) <br />DART Ct)NTAINER <br />1400 VICTOR RD <br />"A 95240 <br />LORI C <br />Generators Phone: <br />6. Transte 1 U.S. EPA ID Number <br />�o anp Name <br />'N S TXR00005093") <br />ZVEW 7L E �YSTEMS, INC - <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address LS CCOLOGY NEVADA o5oso5 U.S. EPA ID Number <br />11 -MILES S Of BEATTY HWY <br />BEATTY NV 89003 <br />14VT330010000 <br />I <br />Facility's Phone: <br />9a. <br />9b. U.S. DOT Description (including Proper Shipping Name, Heard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />— <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />1- NON RCRA ffiUARE-40US WASTE LIQUIEDS <br />DM <br />P <br />223 <br />0 <br />'ttA5,S0iBENT AND 01L) <br />--- <br />2. <br />LLJ <br />HE <br />3. <br />- <br />4. <br />14. Special Handling Instructions and Additional Information SK TRCK#11018a8811 0000371397 <br />SK AUTHORIZED TO RE PS LICE14SED SUBSEOVEHT CARRIERS AS HECESSARY <br />15. GENERATOWS/OFFEROR'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 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 quantity generator) or (b) (if I am a small quantity generator) is true. <br />GeneratoestOfferoes Pdntedffy* Name Signature Month Day Year <br />-1 <br />I- <br />16. International Shipments❑ <br />ElImport to U.S. Export from U.S. Port of entry/exit: <br />9 <br />Transporter signature (for exports only): Date leaving U.S.: <br />0� <br />UJI <br />17 Transpb�irAcknoMedgmentofReceipt afMatedals <br />Month Day Year <br />li— <br />IX <br />Transporter 1 Printedrryped Name Signature <br />X <br />0 <br />Transporter 2 Printedrryped Name Signature Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space Quantity ❑Type ❑ Residue ❑ Partial Rejection El Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />Zi <br />U <br />Facility's Phone: Month Day Year <br />Lu <br />18c. Signature of Alternate Facility (or Generator) <br />19,. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />3. <br />7 <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Be <br />Printed/Typed Name Signature Month Day Year <br />EPf Fr7,Q0-n _ 4 <br />Rey. 3-05) Previous eartions are oosoieie. <br />4 <br />ef,)61 91 3'-5,28/ 40 1014011 <br />JZ31 R 9 104 _\iI'll, 11 <br />