Laserfiche WebLink
Please print or type-(Form designed hof irsa on elite(.12-pitch)typewriter.) Farm Approved.0M8 No.2050-0039 <br /> tJNlFORfd HAZARDt7115 11c;e f 2,P!!ge 1 of 3..Emergency Response Phone 4-Manifest tacking Number <br /> WASTE MANIFEST :: 569-977-628 _ G B F <br /> i <br /> Rik,�dfeBs. Generators Sita Address(it dillarent man mailingr('YL <d'>� 1c <br /> F Traajpditer2 Cgmpgny Name" r s <br /> i' V.(1,EFA Nuinber <br /> B.Das_i9na9ad Facility.t4amn•.arid 3lle Address U.S;EFAlt?Number <br /> tttz�yraprn�:�etivH;e l+�c IR4100025 61 <br /> Wbadvilte�W 6W22, 000-241-200A <br /> Facilll s Phone; <br /> ga. Bb.U.S.DOT D9scriplion(including proper Shipping Name,Hazard Class:ID Number, 10,Containers 11.Tinel 12,lJnit <br /> HM and Paoldng Group(11 any)) „ 13.Waste Codaa <br /> 1 No. ape 'Quantity WI.Nol. <br /> Non-ARCRA Hazardous.Waste 34d <br /> W <br /> Zu 2. <br /> LIS <br /> chis v py <br /> ti is •Y•oi, <br /> 3. <br /> OF RECYCLiNG <br /> 14.Special Handlin Inswctlons andAddl'ttonal Information <br /> 1+ e;All•Pax ftklYk1 C3otbistg ;k1d Eyewe,£ r, 91 -OILY A03OR#3F-ENT C."R, :..,9.1 #171 <br /> 15. GENERATOR'SICFFER0R'S CERT1FfCATION: I hereby declare thatthe conlents of this consignment are fully and accurately described above by the proper shipping name,ar>d we classier,packaged• <br /> marked and labeledfplacarded,and are in all respws In properconclllon for transport aoeording to applicable Inlemaiional and national governmental regulations,Ir export eNpmenl and I am the Primary <br /> Exporter,I ceedfy that Ne contems of this Consignment conform to the temof Ne attached EPAAdowwledgmeni of Consenl, <br /> I certify that the waste minimization etatement Identified h 40 CFR H2.27(a)(If 18M a large quantity generator)or(b)(irl am a small quantity generator)is true. <br /> Generet4r S10ffe nta Prince ITyAed Name Signahye <br /> / Monty Day Year <br /> kT- Akn <br /> T,.r!onat shipmentsI`�l❑import to U.a ❑Eprt nam U.s. Parl of entryMxil:signature(for exporfs only):rAtknrnrA Date leaving U.3.; <br /> Wte edgrnenl W Receipt of Materialst prtntedliyped Name � , <br /> } ql � ftr r Month DayYear <br /> rintediTyped Name I 1z 1 1/ 10 <br /> Signature Month Day year <br /> 18.Disutpancy <br /> 188.Drscrepaney Indlcadon 5peos - <br /> ❑ Quantity ❑Type ❑Residue ❑Penial Re ectian <br /> ®Full Re)ECliran <br /> G 18b.Alternate Facility(or Generalor) MamfestRef4encaNumber: <br /> �r U.S.EPA ID Number <br /> i� <br /> Facility's Phone: <br /> F18c,Stgneture afAllerriate Fadlity or Generals) <br /> Month Day ear <br /> ,.19,Hazardous Waste Report Management Method Codes(l,e„coder,fpr hnantous waste treatment,disposal,and recycling systems) <br /> 4. <br /> 20.Designated FaoIIIty Owner or OperatorCerfiTxeSan of rereipt'of haxardqus maiariafs covered by the manic e�rcepl es ed lnllam t a <br /> Prate 97edName �1 <br /> .., I/V 0 <br /> Month Day Year <br /> ISI <br /> EPA Form0000 221Rev.3-0191 PrAvini iA 'ons are obsolete. <br /> L 'd 96SO "N <br />