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FRT IiII1101I IIIIIIIIIIINIIIIIIIIIIIIIIIIIII <br /> OMB No.2050 <br /> -0039Form APProve . <br /> Please rint or type�HAZARD <br /> 4.Manifest Tracking Number <br /> �Us ��� 2.Page 1 of 3.Emergency Response Phone 9 F L E <br /> !UN�IF�ORM 0159564-21 <br /> 1 8775772669 <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Autozone # 5684 Autozone#5684 <br /> 2099449254 1339 Sutter S 1339 Sutter S <br /> Generator's Phone: StocktonCA 95206 U.S.EPA rA ID Number <br /> 9921 <br /> 6,Transporter 1 Company Name <br /> Clean Earth Specialty Waste Solutions U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> 2JSt Century EMN, LLC U S.EPA ID Number <br /> � <br /> 8.Designated Facility Name and Site Address '_ <br /> 2095 Newlands Dr. East <br /> Fernley, NV 89408 NVD984 5- <br /> CC C�,� <br /> Facility's Phone:7755752760 <br /> 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, Quantity Wt.Nol. <br /> HM and Packing Group(if any)) No. Type <br /> 1 93, Waste Flammable liquids, n. o. s. 1 CF 00003 P 331 i D001 'D035 <br /> o (Methyl Ethyl Ketone, Xylene), 3, PIG 11, <br /> 4 ERG#128 <br /> LU <br /> Z 2. ®_ <br /> Z <br /> W <br /> c� <br /> 3. _,.,.. <br /> z <br /> t s <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 1. 109931 (F l am m a b 1 e Liquids) <br /> 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, <br /> marked and labeled/placarded,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 <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) if I am a small quantity generator)is true. Month Day Year <br /> illSignature B alf of ApZone <br /> Generator'sl0fferor's PrintedlTyped Name 06 Vit}. Eiji` <br /> 16,International Shipments Elxpo <br /> Export from U.S. Port of entrylexit: <br /> ❑Import to U.S. Date leaving U.S.: <br /> t— <br /> ? Transporter signature(for exports only): <br /> W 17.Transporter Acknowledgment of Receipt of Materials Signature Month Day Year <br /> � Transporter 1 PrintedlTyped Name 06 C4 202 <br /> aTrent Pittman Signature Month Day Year <br /> Z Transporter 2 PrintedlTyped Name <br /> Q <br /> f- <br /> 18.Discrepancy El Full Rejection <br /> 18a.Discrepancy Indication Space Quantity <br /> El Type ❑Residue �Partial Rejection <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> 18b.Alternate Facility(or Generator) <br /> J <br /> U <br /> Month Day Year <br /> U- Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) <br /> Q <br /> Z <br /> N 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 4 <br /> 21 <br /> 3. <br /> W 1 <br /> Item 18a <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifestMonth Day Yearature <br /> PrintedlTyped Name mvdc� <br /> 57Q! _ ', . •:. ,t�� v y ��-�'` Y T�EPA`s�-MAN?'LST SYSTEM <br /> EPA Form 700- .12- ' Previous editions are obsole e. <br /> C�'J� <br />