Laserfiche WebLink
�Rv N (7- <br />ep <br />g� <br />Please print or tvpe. (Form desianed for use on elite (12-oiteh) typewriter.) <br />IIINIIIBIIINIIII�IIIYIIIIIRI <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3.05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION 5TA1 t (t HtUUIHtu) <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />G�1000 353qI <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />005863025 $KS <br />WASTE MANIFEST <br />i <br />5. Generators Name and Mailing Address Generators Site Address (if different than mailing address) <br />ti�f�(o�Gcneratora <br />Pnone: 2(� — 3-73 — p a/ (11 <br />6 Transporter 1 Company Name U.S. EPA ID Number <br />, 0 ,. <br />7. Transporter 2 Company me U.S EPA ID Number <br />C ems,,\ Iku Ia4v�7 Ma 0 03-t3VZ5� <br />8. Designated Facility Name and Site Address(Sn �O U.S. EPA IP Number <br />T �1 UVIUC)LJ <br />Cau9tSv%p7Ss27 <br />4 390 <br />� x' �d'r <br />Facility's Phone: ` 1 i <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />tAOLID <br />uJ <br />Z o N C 0.74.► Cho i.�5 u7 aye C r cl �r d� <br />0 -A � OL W� I.eg � <br />� <br />�j OO <br />i- <br />(fie -(AA W v,,jP ,a� <br />�i <br />3. <br />4. <br />I <br />_ <br />14. Special Handling Instructions and Additional Informal& T•cJ) : W I <br />`702'-21 (OkJ5 <br />24 NR Eh'IFRGENCY #1-800-468-1760 15K / TFI <br />f-41IT11 (It' N15. <br />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 labeledrplacarded, 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 ( ) (if I am a small quantity gen r) is true. <br />Ge at 01' sPrinled/Ty Nama ,/—' /� Sign Month � Year <br />14k <br />A <br />J <br />H <br />16. International Shipments <br />❑ Import to U S Export from U.S. Port of entrylexit <br />— <br />Transporter signature (for exports only): Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />W <br />a <br />Tran r 1 Printed/fyped Nar l A ,Q Signatur / Mont /Day Yoar <br />CL L.1 <br />QT <br />2 Pk'n yped Name Si natur Moonnthh Day Year <br />F <br />✓ �� <br />1 �saepancy <br />18a Discrepancy Indication Space C Quantity Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. ARemate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone: <br />Lou <br />18c. Signature of Altemate Facility (or Generator) <br />Month Day Year <br />Q <br />Z <br />a19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />Ul C <br />1, <br />2. kA 1 <br />3, <br />4. <br />20. Designated Fac lity Owner or Operator: Certification of receipt of hazardous materials covered by the manifest exc nded i Item 18a <br />11 1 <br />Pnn Name✓ M h Day, Y r <br />ct �� IK Ck � f n I <br />EPA Form 8700-22 (Rev. 3.05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION 5TA1 t (t HtUUIHtu) <br />