Laserfiche WebLink
Please print or type. (Form designed for use on elite (12-pitchoewriter M <br />0 <br />Form Annrnved. OMR No 91'IS( 03Q <br />"..,,,,,,�,w-.itr. v-v�I,,novruuaaumwisdreuuauiem. C'� T__-DISd-INATEB-FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS 1. Generator ID Number r: <br />2Page 1 df <br />3 Emergency Response Phone <br />4. Manifest Tracking NumberiI <br />WASTE MANIFEST F- :. 1 11 l " 5 : ' '' S <br />4 <br />»'T'-'; 3' R.. i"••++ <br />C <br />0004. 5898 4 VES <br />5. Generators Name and Mailing Address - Generators Site Address (if different than mailing address) <br />g p <br />-04 <br />Generators Phone: ON M-Ple-'4 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />7`- _}1& E -j 7E _I-rAk" <br />. Transporter 2 Company Name U.S. EPAID Number <br />B. Designated Facility Name and Site Address U.S. EPAID Number <br />_^ <br />LC <br />T7-54,, W Ft? ST ,S-TP,EET . <br />Facility's Phone: v2G. c-A-fi417 AZUSA., ��A 01-$32 -1 3, lr -21 ;Z ' <br />9, <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Gass, ID Number, <br />18. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (If ani <br />Quantity <br />WiNol. <br />13. Waste Codes <br />No. <br />Type <br />1 hSC♦.[1i.P:;:RA !-Id,�A. _ri"rtS .4j1iL.;�'F'�, �.r .�. iPFTP(`)f trlj4r <br />:;F•' <br />O <br />— <br />r - k AJT..Q1 d.+STr:-•e �C{t .'ice -i, fS}fl °f', X11' }. _ _ <br />e <br />� <br />c <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />iv1�4R:kZs - NFC£�?t =S: 2} i'-,. 1, EER uarrre <br />15. GENERATOR'SIOFFEROR'SCERTIFICATION: I herehydedam that the contents of this consignmentare fully and accurately described above by the proper shipping name, and are classified, <br />packaged, <br />marked and labeled/placarded, and am in all respects in proper condition fortransport accordhing to applicable intematlonaland national governmental regulations. If export shipment end I em the Primary <br />Exporter; I certify that the contents of this consignment conform tothe terms of the attached EPAAcknowledgment of Consent. - <br />I unity that the waste minimization statement identified in 45 CFR 262:27(a) (d I am a large quantity generator) ar (b) (ifI am a small quantity generator) is true. <br />Generatorsl0fferore Printed/Fyped Name - Signatu 1 Month Day Year <br />f <br />J <br />p-- <br />16. International Shipments �' r <br />El Import to U.S. ❑ Export fmn U,,E. Port 7.nbylezib <br />z <br />Transporter signature (for exports only):*✓' Date leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Printedrryped Name Signature Month Day Year <br />4 <br />Transpoiter2 note yped ame ! r.�r �.�,r�d„ ) Signelfim MDon y yam <br />18. Discrepancy <br />1St. Discrepancy Indication Space <br />❑ Quantity El Type El Residue ❑ PaNal Rejection ❑Full <br />_ Rejectin t <br />- <br />Manifest Reference Number: <br />18b. Alternate Facility Generator) - - <br />(or _ U.S. EPA ID Number <br />J <br />U <br />LL <br />Fadays Phone: <br />Fadlity(or Generator) <br />a18c.SlgnatmeofAltemate <br />Month Day Year <br />z <br />19. Hazardous Waste Report Management Method Codes (i.e., codas for hazardous waste treatment, disposal, and recycling systems) <br />ILL! <br />1. <br />2. 3. - <br />4. <br />20. Desianeted Faclify Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except ,as noted in Item 18a <br />Print edrlyped' Signature --Month Day Year <br />"..,,,,,,�,w-.itr. v-v�I,,novruuaaumwisdreuuauiem. C'� T__-DISd-INATEB-FACILITY TO GENERATOR <br />