Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch)typewriter.) %v I" Farm Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator tD Number 2.Page 1 of 3.Emergency Response PhoneJ <br /> Manifest Tracking Number [] /� <br /> WASTE MA.NIFEST (,tet � I�!` � � �� W�7 as00 01 S - 5 9 DAT <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> W5 5, 4WOU VRY WS 5a RUPORT MY <br /> Generators Phone: 4;fr4YT0R f s 5T-. 45 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 'S INC <br /> "TERT�YCLF SP;:"TAl TY WASTE SOLUTION MNSODOIJ-0924 <br /> 7.Transporter 2 Company Name r U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 21ST CENTURY EWIROMOTAL MWWOM OF WVRIA6 LLV <br /> 2995 lleviansls Drive East <br /> Facility's Phone: _ j <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit. <br /> HM and Packing Group(:d any)) 13.Waste Codes <br /> Na. Type Quantity W1.Nol, <br /> 1. ilium WSTF. 5.115 MOWN SIVE trill, U.S. 19AMIC Due III <br /> 4 � t � � <br /> � 2. <br /> Irl <br /> � Y. T e <br /> DM <br /> 4. <br /> Df.1 P <br /> 14:Special Handling histruetlors and Addibonet Wormaw <br /> 15. Gt lERA1OR' ERpR S C 11 CA,TI 1:I tiereby.declat a#W the corrterrtg of ltus.t tt anent are fully and acauatety described above:6ythe pmpershipping name,and are class, <br /> marked and.L*Aed4bcardad,and are in apr <br /> ll respects in oper condW-for transport zccordmg 10 applicable international and natiorkal gpvemm antai regulathms,If export shipment and I am the PAmaey <br /> F_VWW,I certify that the contents of this constgnrroent conform to ft lama&of to abed]EPAAckn> ment of Consent <br /> I oettify that the waste minimizatgn eatement identified in 40 CFR 26227(a)(KI am a bo. <br /> quaatitygeneratnr)or(6)(it airs a small qllantity generator) tve. <br /> ftame <br /> Month Day Year. <br /> 1 <br /> z <br /> .htpaA to U.S. �6gp fronU.S.TranVorlersg"m(for exports only): , Purl of entrylexit <br /> Date <br /> '" f <br /> leaving U:S.: <br /> 17.Transporter Advxwbdgriw of Receipt afMaWots <br /> PrinWITyped Name Slgrrature <br /> Month <br /> IL Day Yea <br /> M. Traaspor er.2 PrName � Signature �a Month Day Year- <br /> oc � �� f <br /> t—. <br /> 18.Discrepancy <br /> 18a.Discrepancy indication Space ❑ Quantity 1:1 Type El Residue <br /> ❑Partial Rejection ❑Full Rejection <br /> I.- M.Abffkde Facility(or Generator) Manifesl Reference Number. <br /> -� <br /> U,$-EPA U}Number <br /> C3 <br /> uQ- Facildy's Phone; <br /> W 18c.Signature arAltemate Faedtity(or Generator <br /> Q. Month Day Year <br /> z <br /> 19.Hazardous Wase Re Management Method Codes(i.e.,codes for haze dons waste treatment,disposal,and <br /> 0 7: r 2 r ecYchn9 systems) <br /> 20.Designated Facility Owner or operator:Certiti 'n of receipt of hazardous mated�s covered vered.by the manifest except as noted in Itern 18a <br /> Yl�Name <br /> Signature <br /> �-�� - ,.� M ih Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are ob I ' r ° <br /> so ate. <br /> DESIGNATED FACT i Y T DESTINATION STATE(IF REQUIRED) <br />