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Please print,or type.(Form designed for use on elite(12-0,16)Mwff ter. Form Approved.OMB No.2050.0039, <br /> .J ' UNIFORM HAZARDOUS 1.Generator ID Number 3 2.Pape 1 of 3.Ernelgerny Response Phone 4.Nanitest Tracking Number r <br /> WASTE.MANIFEST �* A r' ' / T 1�' . •�d 7 • JJ K'. <br /> f( / 5.Generators Name and Mailing Address' - Genera Site Address pfdAferent than mailing address) <br /> Pilot Td LLC HAno•t Tcavei`Ptata 817 <br /> MOON ThoMn <br /> itnoxville,�TN.379Ilg!(1 .r' Lt3tii,.CA 96242 <br /> Genaater'sPhone: �f ` ` f ✓'r1 Q OA <br /> S.Transporter 1 Comparhy.Name U.S.EPA ID Number r <br /> •r pATll�Or r.RM�i e,�r►o ori -C,`e►rtititiese:tn�+. f` 't - <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> • � n ln�: A 11A trees C,� if' �1C1Q9F* 7A Z <br /> 8.Designated Favi ty Mame and Site Address • U.S.EPA ID Number <br /> MEOW iO4Vada <br /> Hw 951 fu-1P 4.8ewry <br /> F a <br /> moi,NV SM3 <br /> � _ r% � AIT4 � ft'A11A , <br /> 9a. 9b.US.DOT Description pndudi g Proper Shipping Name,Hazard Gass,ID Number, y v 10.Containers 11.Total .12.URN yW 13.Waste Codes <br /> HM and Paddrnp�+pOfany)) i No. '' , Type Quantity WWoI. ,k10 , ; <br /> Non-R ' hazardous•waste,Niquid (oily wat6r) d�P DAA <br /> W / <br /> Non-RCRA hazardous waste,solid(*By debris) 0 � -DM 0150 P <br /> 3. <br /> Af <br /> ' •' � � pf��r....�;. '• �• ,M,� .• fit. '•� y�; A • •'• .e.•'•• '�'nAr! <br /> •wr 4. •. . yy, ..•1y,�!t"-;��'• r r M f►r• •Y •l 'r'' {'rl y�•f'' .a {t <br /> t 14.Specal HandlinginsWctiana a id Additional Information <br /> '191111.P,rofirg ol7y water)# SIM.Profile# �.toii�I.•de�) <br /> P4#741374 <br /> Job X18-1620 t Yea. r' <br /> 15. GENERATOR'SIOFFERr CERTIFIC"TION:I hereby dedem that the contents of this consignment are fully and accurately desci above bythe proper shipping name,and are dassM.packaged,` �r <br /> marked and labeled/placarded,and arein all respects In proper condition for:transport scmrding to applicable Intemational and national govemmental regulations.If export shipment and I am the Primary , <br /> Exporter,I certify that tine contends of this consignmentcorhtor n to the"'of the attached EPAAdmowledgment of Consent f' <br /> I car*that the waste jqRmIzation statement idend6ed in 40 CFR 282f 7(a)(d I am a large quantity generator)or(b)Of I am a small quantity generatorjAue. ' ;p <br /> Generator'sl0fleroesPdntedfTypedName «�.r" ! :ti lure Month Day "Year ref <br /> 16.International Shipments ' <br /> ti ❑Import to U.S'S ❑Export from U.S. Port or entryferdt i I' <br /> Transporter signature(for exports only):. +" Date leaving U.S.: <br /> W 17.Transporter Aouwwledgmend of Receipt of Materials ' ' ' ~ +•:d <br /> 6 Transporter 1 PdhtedMW Name Signature Month , Day Year 7� <br /> OC' • <br /> - 1 <br /> Transporter 2 Printed/Typid Namy Month Day Year '. <br /> 18a.Discrepancy Indication Spacer <br /> . Or Quan ❑Type _� • Q Residue; :0 Fardel Repscfiwn• _ •�FuY,ReJeetion <br /> ' ManW Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Num - <br /> Faditys Phoria:;- <br /> W 18c:Signatureof AltemateFaddty(or Generator) Y Month Day�• Year <br /> CO) 19.Hazardous Waste Report Management Method Codes(is.,codes for hazardous waste treatment,disposal,and m4dng systems) "'A , <br /> In141, <br /> J <br /> 20.Designated FadlltyOvViorOPerator Certification ofreceipt of h o materials covered fry the manifest except as n4ijitem 18a,' <br /> P /Typed Name Signature Month Day Year <br /> EPA Form 8J0022(Rev. ) .re ' ushtion are obsolete. DESIGNATED ACILITYTO GENERATOR STATE(IF REOUIRiD))- <br />