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01 <br />S <br />,y <br />Please nrint�nr tvna. /Fnrm dasinnad fnr usw nn alita I19�ifrhl h—ritar I <br />r <br />DE ATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />10847.0445 <br />UNIFORM HAZARDOUS <br />1 • Generator ID Number <br />w <br />2. Page 1 of <br />3. Emergency Response Phone 14. <br />Manifest Tracks Number <br />WASTE MANIFEST <br />2 <br />( 800) 424-9300 <br />007 7 14 9 JJ <br />S. Generatoes Name and Mailing Address . Generator's Site Address (if different than mailing address) <br />Fedex Freight V I'M FREIGHT (STK) <br />4520 SOUTH H16MMY 99 FRONTAGE ROAD 4510 SOUTH HIGMY 99 FRONTAGE ROAD <br />cenEMBON C1 SS215 121121456-2127 ISTMTOV CA 95215 (189)466-2127 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />AL MANAGEMENT OF NEVADA LLC NVD980895338 <br />7 sporterCompany Name140 U.S. AID Number <br />/ <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />.GENERAL ENVIRWENTPL INET, LLC DBA PSC ENIMIENTAL SERVICES <br />11855 VHITE ROCK ROAD <br />Fad Phone: MMIG, C1 ISM 19151 ISI -1280 <br />COBS, 11884183' <br />- <br />9a, 96• U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit <br />13. Waste Codes <br />HM and Packing Group (if any)) No. Type Quantity Wt vol. <br />ac <br />1' UNIO66 (TASTE RESIN SOLUTION, 3 PGII <br />DOOI 271 <br />� <br />X <br />DM <br />P <br />_ � <br />z' NON-RCRA HAZARDOUS HASTE LIOM (SPONGE ]MTN) <br />331 <br />DM <br />/ <br />3. NOH-RCRA HAZARDOUS VRSTE LIQUID (SOAP) <br />561 <br />DM <br />a'NON-RCRA HAZMOUS PASTE SOLID (LAHOTRI6IHE'151016 TALBEfS) <br />311 <br />� <br />DM <br />, <br />P <br />14. Special Handling Inductions and Additional Information X 8 �� a i ••�V <br />(1) FEFRESINSOL-81 - ERG(127) PRO$ 1983946925 VAST (2) IQ -01 - PRO# 2091730480 NON (3) FEFRONHAZLI11-00 - PRO$ <br />2016590660 NON (4)" ZSOL-00 - PRO$ 11052224542 NON <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: (hereby declare that the contents of this cot* are fully and aocura descried above by the proper shipping name, and are classified, packaged, <br />marked and labeled/placafded, and are in all respects in proper condition for transport according to applicable international and national govemmental regulations. if export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terns 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) (di am a small quantity generator) i <br />GeneratoesfOfferoes Printed/Typed Name Signa Month Day Year Olt <br />V <br />2 r Q rio /! ,� 1 <br />.J <br />�- <br />16. International Shipmen <br />❑ import to U.S. ❑ Export from U.S. Port of entry/.*. <br />Transporter signature (for exports only): Date leaving U.S.: <br />U <br />17. Transporter Acknowledgment of Receipt of Materials <br />OTransporter <br />1 Printed/iyped Name Signature Month Day Year <br />% <br />"/ /d <br />2 a Si r Month Day Year <br />rslfrtw <br />Zj: <br />1A A jtInt e Z. /o <br />18a. Discrepancy Indication Space ❑ Quarmy ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />�18b. <br />Akemate Facility Aar Generator) U.S. EPA ID Number <br />6„ i <br />6`4f- <br />• <br />Facifdys <br />W <br />Phone: <br />18c. Signature of Aitemate Facility (or Generator) Month Day Year <br />Q <br />Z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />®1 <br />2. <br />3. <br />4. <br />—41119 H141 <br />H111 <br />1.4ftm QLA <br />H141 <br />20. Designated Facility Owner or Operator. Certificatiof of rept of hazardous materials covered by the est except it noted in <br />rxttedfTyped Name S afore Month Year <br />DE ATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />10847.0445 <br />