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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID NumberPage 1 of 1 3.Emergency Response Phone Manifest Tracking Number <br /> rl <br /> WASTE MANIFEST =AL000427614 9775'!72669 4. F L E <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Bath 8 Body Work=_ E5 Batt`: R Lrdv 14c, <br /> 2099524396 5308 PACIFIC AVE, SHERWOOD MAL / SPACE 6 5308 PACIFIC AVE <br /> Generators Phone: c;TnrkTnN, ca c2-, c <br /> 6.Transporter 1 Company Name U.S. PA ID Number <br /> 7.Transporter 2 Comp Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address :lst Century EMN, LLC U.S.EPA ID Number <br /> 2095 Newlands Dr. Ea=-t <br /> Fernley, NV 89408 <br /> FacilitysPhone: "7'755'752760 q=.� <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11-Total 12.Unit <br /> M and Packing Group(if any)) 13.Waste Codes <br /> H <br /> No. Type Quantity WI-Nal. <br /> X 1UN1950, Waste Aerosols, [flammable, (each not 1 CF 00016 P 331101001 ; <br /> a exceeding 1 L capacity)3 2. 1. ERG#12E <br /> W <br /> Z 2. <br /> UJI <br /> tU <br /> 3. <br /> _._...i..__.._ <br /> I <br /> 4. i <br /> t <br /> e <br /> I <br /> 14.Special Handling Instructions and Additional Information <br /> 1, 110`304(Aerosols, Flammable) <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of[his consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental r 0 ions.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) ' am small quanti gen to is true. <br /> Gen rotors/Offerors Printed/Typed Name ,gna re CL rep - 1 of L 1 A'i t e on ay ear <br /> 1 < <br /> J 16.International Shipm s <br /> F— ❑Import to U.S. ❑Export from U.S. d o entry/ex' <br /> z <br /> Transporter signature for exports only): D t eavin U .: <br /> w17.TransporterAcknowledgment of Receipt of Materials <br /> Transporter 1 Pdntedrryped Name SigDAure Month Day ear <br /> O 1 071 1312011EA411 <br /> AnthonyMack <br /> za Tra iter 2 PrintedfTyped Name ature Month Uay Year <br /> t" <br /> rL(' ? n / <br /> 18.Disgrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑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 /> L Facility's Phone: <br /> W18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> Fn19.Hazardous Waste Report/Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LAJ� I 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Ba <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 870O-22(Rev.-3-05) Previous editions are obsolete. DESIGNATEF-i FAQ` . Y I<c; "T':fi" 'iV STATE(IF RE;4U!9EE, <br /> 8700-2212v3 C8293378 541067816 041140682 M PD071318 SD071318 - <br />