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1 42 <br />Please print or type. (Folin designed for use on elite (12 -pitch) typewriter) <br />Form Amoved. OMB No. 2050-0039-:--,„•: <br />t:FA I-OrTn d[UU-ZZ (Kev. jj wevious eronsilarwomete. <br />1)6987369/404 .4976 <br />10839.1166 <br />SIGNATED FACILITY TO GENERATOR STATE IF REWIRED) <br />UNIFORM HAZARDOUS ID Number <br />CAL1309167732" <br />2. Pa I of <br />2. <br />3,tn Tgg !!fjnb 14. <br />1 <br />Manifest Tracking Number 4" <br />00335717*2 PLE <br />WASTE MANIFEST 1 <br />5. Generator's Name and Mailing Address Generator's Site Address (it different than mailing address) 4' <br />FEDEX. FREIGHT WEST FR <br />4520 S. HWY 99 <br />STOCKTON CA 95215 <br />Generator's Phone: 2109-466-1M <br />6. ra s rte 11 Cc Mame U.S. EPA ID Number <br />Ell•-.• SYSTEMS, INC. TX $5$93$ <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Design ated Facility Name and Site Address US ECOLOGY --NEVADA U.S. EPA ID Number <br />. <br />11 MILES S OF-8Z9jjY- HWY 95. <br />14 <br />BEATTY NV 89003 <br />BN -239-3943 NVT330010"0 <br />Facility's Phone: <br />9a. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12, Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Pa&ng Group (if any)) <br />Quantity <br />WLNOL <br />NON-RCRA'HAZARDOUS WASTE SOLID <br />DM <br />P- <br />352 <br />.(DIRT AND' BURLAP ) <br />CY <br />2t <br />LU <br />3. <br />4, <br />14. Spedal'Han.dling Instructions and Additional Information SK SHI 1952970 CSG: <br />I ol; 115", A <br />(go <br />24 -HR EMERGENCY -#1-812110-468-1760 (SAFETY-KLEEN 94138) <br />SK AUTHORIZED TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY <br />15. GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contents of this 66nskjaa*nt are fulty and accurately described above by the proper shipping name, and are classified, packaged, ) <br />marked and labeled/placarded, and are in 611 respects in proper condifion 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 coriform 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 />Generator`!1105erofs Printed/Typed N Signapy Month Day .78jr <br />Ma'Or." ez I oil -11 I I ID <br />_J <br />16. International Shipments . � ""t I <br />0 Import to U.S. El Export from U.S. Port of entrytea <br />Transporter si22alure (foreArts on fft Date leaving U.S.: <br />tAj <br />17 TransporterAcWbWedgmint of Receipt of Materials <br />' 1 4 <br />tE <br />0 <br />Transporter I Pr1nlpdrrMfNa* Sgn tur 9'/ Month, -Day ear <br />Ae'v W <br />CL <br />U) <br />ALA-ftem-- A WIZI. <br />Z <br />Transporter 2 Printed/Typed Name signature Month Uay . Year <br />18, Discrepancy <br />l8a. Discrepancy Indication Space EJ Quantity 1:1 Type El Residue n Partial Raj ull Rejection <br />action D F <br />Manifest Reference Number. <br />18�Alternate Facility (or Generator) U.S. EPA ID Number <br />u- <br />FaciliVs Phone: - <br />W <br />Signature of Alternate Facility (or Generator) Month Day Year <br />19. Hazardous Waste Regort Management Method Codes (i.e., codes for hazardous waste treatment, disposal, an(rrecycling systems) <br />l4i <br />1 <br />2.- <br />20. Designs Wdr Fa&lity Owner or Operator. Cerfificatlog ofjKij ofhW "�,cove covered manifest Wous me s r a If except as n9lid in I!pm 18a <br />"Fn tedfTyped Name Signature Year <br />t:FA I-OrTn d[UU-ZZ (Kev. jj wevious eronsilarwomete. <br />1)6987369/404 .4976 <br />10839.1166 <br />SIGNATED FACILITY TO GENERATOR STATE IF REWIRED) <br />