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Please Dri.,or twe. Fnrm Annmvp.d OMR Nn qn.qn-wiq <br />-1 Willi U1 -« klAVV. !L-11) r-ft:VIVUbUUILIUIlbdie UUtiU!t!LU. DESIGNATED FACILITY TO EPA's e -MANIFEST SYSTEM <br />UNIFORM HAZARDOUS <br />1. Generator !D Nu <br />2. Page 1 of <br />3, Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />I � 1 <br />1 012494806 FLE <br />5. Generator's Name and Mailing Addres,s Generators Site Address (if different than mailing aAdress.) <br />Z:)t a pie s retail #1341 t a 0 1 e s 3 1 1 #j.11" 4 1 `41 <br />- # i <br />t'--'49 Commerce Avenue 249 Commerce Avenue <br />Generators Phone: MANTECA, CA 95337 MANTf- 7:=j,: F 95337 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />...-tpric7yrle Soecialtv Waste Sinlut iontz i n c MNS0001110924 <br />7. Transporter 2 Company NameU.S. EPA ID Number <br />17IC4 �� <br />8. Designated Facility Name and Site Address List Century EMN, LLC U.S. EPA ID Number <br />2095 Newlands Dr. East <br />Fernley, KIV 89408 <br />Facility's Phone: <br />9a. <br />91b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.1vol. <br />13. Waste Codes <br />No. <br />Type <br />1 _nr W i - IS, L T -i R hu M 0 L E, Gi C <br />L)-,, <br />;L <br />0 <br />exceeding 1 L capacity)i `.1, ER13#12% <br />Z <br />2. <br />UJ <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information 1.103090(Aerosol s, Flammable) <br />15. GEN ERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, at are classified, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable internationaland 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 EPA Acknowledgment 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) (III am a small quantity generator) is true. <br />Genera <br />I r's Printed/Typed Name P Signature Day Year <br />16. International Shipments <br />0 Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />Z <br />Transporter signature (for exports only): Date leaving U.S.: <br />iX <br />LU <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printed/Typed Name Signature Month Day Year <br />0 <br />[L <br />"j <br />Z <br />-i I a; J <br />I TranstJ <br />porter 2 Printed/Typed Name Signature Day Year <br />M? /9 <br />18. Discrepancy <br />18a. Discrepancy Indication Space El Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />-J <br />U <br />is <br />Facility's Phone: <br />LO <br />Li <br />T8c —Signature of Alternate Facility (or Generator) <br />-711 <br />nth Day Year <br />!7( <br />Z0 <br />55 <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LL! <br />3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />7;— <br />Printed/Typed Name Signature Month Day Year <br />"74V <br />1 <br />-1 Willi U1 -« klAVV. !L-11) r-ft:VIVUbUUILIUIlbdie UUtiU!t!LU. DESIGNATED FACILITY TO EPA's e -MANIFEST SYSTEM <br />