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6S G'9k-T I 292)472. <br /> Please print or type.(Fort designed for use on aiite(12-pitch)typewriter.) y� i <br /> Wt f✓ Form Approved.OMB No.2050-0039 <br /> i.Generator Ip Number Phone 4.1Nanffesl racid 14 be <br /> U <br /> NIFORM HAXARDtJU5 En7tt <br /> .3� �� 'f ���� � J�'7— <br /> TEMANlPE57OALU00391G74 ?--, f7 l(�J �!'ll <br /> ators Name and Ma ingAdd ess Genorators bAcAddrass{'d dlffereat then+Hating address) <br /> LOTS SICREs BIG Env D )�� <br /> f4lLj kr` R9 RT r}t: BERfl RRRU 381 S CHs RQKEE LRE <br /> ftPhone: MUMS ell 43228 f�I41I76-1796 LODI 4 9x248 <br /> orter 1 Company NamU.S.EPA IDNurr�er <br /> RICYCLE SPECIALTY WASTE SOLUTIONS INCP]I9SflOfllTtf�)�4orter 2 Company NameU.S.EPA IDF.W,ted Factity Nance arxt SireAddress <br /> U<S.EPR ID Number <br /> 71ST CENTURY ENVIROMML I1A1IA6EMENT OF NEYAD4r, [LL <br /> 2045 Neviands Drive East <br /> FaciWsPtwne; L£RKLET NY 19404 (775) 575-2764 i�fV 96Qfl�5 3 <br /> ga. 913.U.S.DOT Description findaigN proper 5140ft Narne,Hazard Class,)D Number, 10.Con7aiaers 1 <br /> HM and PaajQ&uup(if am!)) 1.Total f2.Unit <br /> No. Type Quantity WLA/d. 13.Waste Codes <br /> � 1. Ut(f9§13 f7A5TE AEROSOLS 2.I ((�(D111=11141 331 DDOl <br /> 2. <br /> X r <br /> 3. UN336 WASTE CORROSIVE LIQUID, JASIC, IiIG1467i}IIC, R.O.S. I SIM 141 DV62 <br /> X HYDROXIDE, POMSSIO1 MIMIC 1 P6II R00112=3191 P <br /> d• UtN1993 HASTE FI-MM11 LIQUIDS, K.O.S. (KEI(OW, DIESEL) 3 KII :131 3111111t®15 <br /> X RQ(1i111=140) , P <br /> 14.Special Handling lrrstrudiorts andAddMMI Inkarnabon IiD07 1019 "35 <br /> (11 1i1IR05IkS 43 _ Elt�(12a) iIERQSOLS ( (3) �CORHlASIC-d:l FR6€154) <br /> iASIC MROSIt1E LIQU (4) ILFLWIQ-13 _ MUM FLM*E LIQUIDS <br /> 15. GENERATDR'& TERM'S CMFiCATM:1 hereby dec3ere Ihat lino mntaat d oris consignment am fully and acaratety deso ibed above by the g <br /> marked and labeledfptecarded,and are h au respects b Proper wndltan for r Per shlPAin name.a d are'Jassified,padraged, <br /> t artsport a zordir�q to applicat to iotemateoHaland rs-60 ml governmenlal reguladons.If export stripment and f am the Primary <br /> Exporter,l oetirfy ft'the co**of this consignment crxdorm to the terms of lite attached EPAAdumwletrwt of Consent. <br /> I certify that the waste rninfnune n statement Identified in 40 CFR 25227(a)f'd I am a large quarlttly generator)ar(b)(ii f am a small uantity genemiM is true. <br /> ratarslOfterot s Na re <br /> liL T 1 <br /> Month Da <br /> 16. erne tSftpments ( I (((JJJJ) <br /> z 167p01tg'3l.S• ❑ bwntJ.5. cfenttylexit__ <br /> -- Transporter signahua(for erports and y): 14;aVrtg U.S.: <br /> LM 17.TranspprterAdv*wWgrrrentafReariptofMalerrais <br /> Transporter 1 Prwedrrlyacne <br /> signature <br /> p Month Day Year <br /> fn at Qy-kRR. <br /> Q Trans rtor 2 Pr ntName Sign 4 <br /> hloHgt Day Year <br /> t 8.Discrepancy <br /> 18a 13isc spancy indication Space El Quantity Q T <br /> YDe ❑Residue ❑Partial Re)ecten 1._t Fug Rfjecfiort <br /> 18b.Rkemate Facility(or Goneraforj Manifest Reference Number. <br /> U-S.EPIC ro'#umbar <br /> U <br /> Facsrty's Phone: <br /> W 18C.Signature of Altemate Fac4rry(or Generator) <br /> z Month Day Year <br /> 19.Hazardous Waste ROW Managemant Atefltod Codes(.e.,codes far hazardous waste treatment,disposal,pawl,and recyding systems) <br /> 2. 3 <br /> 20- 4 <br /> 7` l/ice/ <br /> Des pealed Fadlily D++ner of Operator CMification cf ne'*t of hazardous materials covered b gq marifosf ax <br /> Print Yped Name Y c*as noted in Item 18a <br /> r— <br /> nalure <br /> EPA Force B D 2(Rev.3- 5) Previous editioos are oielrl. <br /> DESIGNATED FACILITY TQ C3ESTiNATION STATE(IF REQUIRED) <br />