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�� <br />Please print or type. <br />UNIFORM HAlARDOUS <br />WASTE MANIFEST <br />••6;5 y <br />-- CVS ISIS) #16223 <br />2@98333494 2B@@ Naglee Rd, Suite H <br />•a:f[ <br />(dress 21st Century EMN, LLC <br />2095 Newlands Dr. East <br />Fernley, NV 89408 <br />m <br />•���•�• � rrrr• <br />� • <br />9a. gb. U.S. DOT Description (induding Proper Shlppirg Name, HazaM Class, ID Number, <br />HM and Packing Group (ff any)) <br />X1' UN2811, Waste Toxic solids, organic, n. o. s. <br />(Chroeiva, Seleniul�), 6. 1, PG II, ERG#154 <br />O,�%' <br />u.s. <br />10. Containers 11. Total 12. Unft <br />No. Type Quantity WtNol. <br />i CF 00001 P <br />1.1@@196tRX Toxic Solids ) <br />�/ <br />t3. Waste Codes <br />31 <br />IS <br />15. GENERATOR'SIOFFEROR'SCERTIFICATION: (hereby dedare that the contents of this consignment are fuly and accurately described above by the proper shipping name, and are dassified, packaged, <br />marked and labeled/placerded,crnd are in all respects in proper condition for transport according to applicable lntemationaland national governmental regulations. It export shipment and I am the Primary <br />Exporter, I certify that the contents of this kxmsignment coMorm to the terms of the attached EPAAdcrawiedgment of Consent. <br />I certify that the waste minimization statement ldenti8ed in 40 CFR 262.27(a) (ff I am a large quantity generator) or (b) (ff I a ntity generator) is true. <br />Generator' erors Print !Typed Name Signahrre Month Day Year <br />��... ;�� S'C�rrvu� nic�`-F I � I i � la�i X01 <br />� w.r�����a.��w��,�,N„A"w UlmporttoU.S. <br />? Transporter signature (for exports only): <br />Fr 17. TransporterAdcrwwledgmant of Receipt of Materials. <br />18. Discrepancy <br />18a. Discrepancy Indicetion Space <br />18b. Allemate Fadlity (or Generaic <br />J <br />rJ <br />FadliNs Ntwne: <br />Hazardous Waste Report <br />1. <br />❑ Quantity <br />Export from U.S. Port of entrylexit: <br />Date leaving U.S.: <br />❑Type ❑Residue <br />Codes (i.e., codes for hazardous waste treatment, <br />Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as octad In Item 18a <br />/'\ � _ 1 � _ z Stgrr�re %�� <br />editions are <br />❑Partial Rejection <br />Year <br />❑ Full Rejection <br />DESIGNATED FACILITY TO EPA's e•MANlFEST <br />