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RECEIVED BY SJCEHD (EF) on 4/20/2020 <br />Please Drint or tVDP.. <br />mnnumii <br />{// ( DESIGNATES Fj4CILITY TO EPA's e -MANIFEST SYS7EM <br />3700-�',=°r...123 08269 7 96 5410-110 X20 74142 35A+0 M (F/D0 6061 q 'jK-5 066 i °� <br />,.Nr,,,. ,,.--- .v <br />UNIFORM HAZARDOUS 1 Generator ID Number 2. Page 1 of 3. Emergency Response Phone est Tracking Number <br />WASTE MANIFEST FLE <br />76013120694 <br />5. Generator's Name and Mailing Address'"` m 3 Ger erator's Sife Address (ii different than mailing address) <br />Ltm '--F=a :% 2 350 W. ,•.E t TL EMAN LANE SUITE .12. - <br />Generator's Phone: <br />6. Transporter 1 Company Name ""U.S. EPA IDNumber" <br />_. Ui A DNumber <br />7. Transporter 2 Corripany Name17— <br />r� <br />8. Designated Facility Name and Site Address ; EI_ U.S. EPA ID Number <br />a t 4?nti:r'y EMNLL- <br />I r`nl?r, NV 894117118 <br />Facility's Phone:..- <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10, Containers <br />11 Total <br />1�2. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />13. Waste Codes <br />No. <br />Type <br />o <br />WthyI Ketone?. 2.1. ERt3#I2E <br />U.1 <br />2. <br />LU <br />c� <br />3. <br />i <br />r <br />4. <br />i <br />t <br />14. Special Handling Instructions and Additional Information y �� r r k{, <br />�. a 1�vs,s�y iJ i?'t41''+rS :fo17 f_Ot�3et',3 C�t_`�4 <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described the proper shipping name, and are classified, packaged, <br />agboby <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national goental 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 ConAnt. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b)'a a small qu tit .generator) is true. <br />Gen tor's/Offeror's Printed/Typed N me Signature ,. a Month Day Year <br />Z <br />16. International Ship ents - <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/ex(t: <br />Transporter signatur (for exports only): Date Ieaving�.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />OTransporter <br />1 Printed/Typed Name Signal re Month Day Year <br />W <br />Q <br />aF- <br />Transporter 2"Printed7ypedName 2ignatur Month Da Year <br />V <br />18. Discrepancy <br />18a. Discrepancy Indication Space <br />Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b, Alternate Facility (or Generator) <br />J <br />U.S. EPA ID Number <br />U <br />Facility's Phone: <br />w <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />4 <br />Z <br />H19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LU <br />p <br />1. esy / / <br />2• <br />3. <br />4. <br />20. D/esignnated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest ekcept as noted in Item 8a <br />PrintedlTyped Name - _ SignotV Month Day Year <br />-� <br />/c <br />{// ( DESIGNATES Fj4CILITY TO EPA's e -MANIFEST SYS7EM <br />3700-�',=°r...123 08269 7 96 5410-110 X20 74142 35A+0 M (F/D0 6061 q 'jK-5 066 i °� <br />