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s ,A 435127 P�lr-print or type. (Form designed for use on elite (12•pitch) typewriter.) AK -0 � 0�a' >- Cj- - 0 Is 18- 1295836 Form Aporoved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. ( j DESIGNATED FACII-1770 DESTINATION STATE (IF REQUIRED) l.I 10917.1359 (//� ID Number UNIFORM HAZARDOUS 2. Page i of Response Phone 4. Manifest Trackin Number WASTE MANIFESTCALOOD167732 [=I 1800) 7Emergency 424-9300 ®0 0 0 3 016 ®AT 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) Fedex Freight FEDEX FREIGHT (STK) 4520 SOUTH HIGHUAY 99 FRONTRGE ROAD 4520 SOUTH HIMRY 99 FRONTRGE HORD Generfflffla Gfl 4 (209)456-2121 ISTOCKTON CR 95215 (209)466-2122 6. Transporter 1 Company Name U.S. EPA ID Number s Environmental Management of Nevada LLC INVD980895338 7. Transporter 2 Company Name U.S. EPA ID Number 21st Century Envimmeatal nananement fCalifornia-P CARO 02106 7 8. Designated Facility Name and Site Address U.S. EPA ID Number GENERK ENVIROKNgffRL W, LLC DBR PSC ENVIRONHENTRL SERVICES 11855 VHITE RUCK RORD Facility's Phone: 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Gass, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (f any)) Quantity Wt.Nol. 1' UN1253 VRSTE PRINT MUTED MTERIRL 3 PGII ROOM DD01 214 DIM p w 2' 11111179 URSTE 3 PGII R®(D001) D091 212 DPf 3. 4. 14. Special Handling Instructions and Additional Information 7 I K 10 (1) FEF314-06 - ERS(128) PROS 2308297961 MPRH ( - 15. GENERATOR'SIOFFEROR'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, marked and labeledlplacarded, 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAdmowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (d I am a small quantity generator) is true. Generator'yOffemes Printed/ryped Name Signature Month Day Year S k r -v /V ZElImport 16. International ShipmentFj Port of entry/exit to U.S. ElExport from U.S. t: Transporter signature (for exports only): Date leaving U.S.: LU 17. Transporter Acknowledgment of Receipt of Materials �j Transporter 1 Printed/Typed Name Signature I, y Month Dayj Year CL Vl Z Transporter2Print Name �-�--+ Signature MgnthDay Year 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Altemate Facility (or Generator) U.S. EPA ID Number V Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year Z CD US 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) LAJ t. 2. 3. 4. HI41 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typo Name M Signature`^ Month �7Day Year cc' EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. ( j DESIGNATED FACII-1770 DESTINATION STATE (IF REQUIRED) l.I 10917.1359 (//�