Laserfiche WebLink
P type.( g typewriter.) `_ - • '- Form Approved.OMB No.2050-I <br /> Please tint or e. Form designed for Use on elle( h)lyp ) p page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS 1.GeneratorlD Number 001139847 F LE <br /> WASTE MANIFEST - - - - - <br /> 5.Generators Name and Mailing Address)MANIFEST —Generators Site Address(it(firman,than mailing address) <br /> Generators Phone - U.S.EPA ID Number <br /> 6. renspoderi ompany Name ,i F, _ - - _ <br /> .;teen 1-,3,0-ars U.S.EPA ID Numher <br /> 7.Transporter 2 Company Name <br /> U.S.EPAID Number <br /> 8.jtesignated Facibty Name and Sde Address" 7 <br /> art, i{ LIT�n28 <br /> Facililys Phone: (�'-I, �'"` <br /> 10.Containers r- <br /> r) <br /> Waste Codes <br /> gra 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, <br /> HM and Packing Group(if any)) No. Type . . ;�_ r.�(oA. _2.RQ.P�Ji_Y��1-i, IG Imo.�:= ' SSOLID,@:Jfd;�';Pc {i s f, r) Pvi 4.�` ..u'J-. ;i 1;=.,v_,. , D _ � n AA <br /> 14 SpeGal if O linMai $NsfmctionsandAdditj4nSLlnJor a�r'QQ; j. 0}-('i' 55g6 1461 BOXc?x4FT B0�G IL50 <br /> 4: v„SSD;1^vwD-.�152J057' 4. CHZ. gam°;. 3:� fr'. �o-k•I <br /> 2 C ri2538.. <br /> PCB CONTAINER 10#FPC9-C�'iY?2-i;r+.,1�7 ,003,t4,005.i�5,t7, Lr°'y0',+' <br /> l+�if9f <br /> C. 5046,L =iEL 4F442106 Feat* <br /> 15. GEN ERATOR'SIOFFEROR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are Nlly and accurately described above by the proper shipping name,and are dassified,packaged, <br /> marked and Iabeledlplacarded,and are in all respects in proper condition for transport according N applicable international and national governmental regulators.If expert 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 cerdty that thewaste minim'nation statement identified in 40 CFR 26227(5)(111 am a large quantity generator)or(b)(if I am a small quantity generator)is true. on ay s <br /> ' eneratorsl ero s Pnmed(Typed Name n re _ <br /> LOG/ 3 ' 7�0 Mhz ; <br /> 16.International Shipments ❑Import to U.S. ❑Expodtrom U.S. Pod of entrylexit _ <br /> iDate leavin U.S.: <br /> Trans orter sl nature for exports only): <br /> W 17.Transporter Acknowledgment of Receipt of Materials on ay e <br /> Tra porter LPrilded[Typed Name ignaNre <br /> Ys <br /> 4 Transporter 2 PdntedlTyped Name ignature <br /> }nth Day <br /> K <br /> F- <br /> 18.Discrepancy <br /> ties.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> 181b.Alternate Facility(or Generator) <br /> J <br /> U <br /> ra+-FSWWd <br /> ' ne: Monthre of Alternate Fatality(or Generator)s Waste Report Management Method Codes(i.e.,codes for hazaMous waste treatment,disposal,and recycling systems)C2. 34ed Facility Owneror Operator:Certification of receipt of hazardous materials covered by the manrfestexcept as noted in Item 18aMonth Day Y' <br /> d Name <br /> Signature <br /> CPfi€ 153 tg y z�cQns�a.ghFage, - 3 - . s,ens,etev=n_ratorjgE I IAEDFACILITY TODESTINATION STATE(IF REQUIF <br />