Laserfiche WebLink
Published by J.J.KELLEA&ASSOCIATES,INC.,Neenah,WI•USA•(800)327-6858•www.jl mger.com•Printed in the United States 167-BLS-C 6 1049 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Foan Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2 Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C A 12000 d ! I-So D.SS6/ jioA 0 01171141 JJ K <br /> 5.Generator's Name and Mailing Address Generator's Site Address(d different than mailing address) <br /> B P--w 23 4-- C.a a.T L ra c(U is �.�L <br /> e2-766 -6U�ti1,3,1 ,� bt.� ��a��_ 66 �L)Lia -2 <br /> Generator's Phone: S 4—:0e-�O---, CA <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Av\c a ; Q- o 06 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.LPA ID Number <br /> `flew\e-V'-ha PL er of oo,n. <br /> Alli 15 A) 0.\a e c(O.,S_�_ Ca M Q�o I, e_ 4 �'1 G <br /> Facilitys Phone: I J Q� <br /> 9a. 9b.U.S.DOT Description(including Proper Shlpping Name,Hazard Class,ID Number, 10.Containers 11.Total 12 Unit <br /> HM and Packing Group(if any)) No. Type Quantity WtNol. 13.Waste Codes <br /> 1. <br /> o 1b e ot114 foo( a <br /> X2� vNos rod@vwx <br /> z 2. <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional information 4 �I <br /> ?e 4-+--Le r Vyt.�, H Ya 10 CC C V1- �' 1 t1� S 14:s cit 2d 5'0 l <br /> (qL:9 Aq<.- ` fob 1:t 3 6`1 - 1G t S' A-V(Cot✓` -3i;- (1565 <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 1 am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generato,'slOfferoes PrintedlTyped Name Signature Month Day Year <br /> 'l" j �S <br /> =-+ 16.international Shipments —I <br /> T-- ❑Import to U.S. — _❑Exoort from U,S�_ Pod a trylex b <br /> z <br /> Transporter nature for exports <br /> � g t pe ----- <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> 7r nsporter 1 P iota ed Name �..}-0 ay Year <br /> CL <br /> nsporter 2 Printe yped Name paylay Year <br /> t <br /> 18.DiscrepancyI (�j1. <br /> , f �(/,K\(/t/J/Y(J <br /> 18a.Discrepancy IndicaEon Space El Quantity L—'� IT Rejeciien <br /> Alternate Facility(or Generator) <br /> aclitys Phone: <br /> W 18c.Signature of Allemate Fadlity(or Generator) I Day Year <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes <br /> Ul <br /> 1 2 � - <br />