Laserfiche WebLink
• / `" 00206:0629. <br /> Please printor type (Form designed foruse on elite(12• 'tch) 15(. 0 Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.G orator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manow Tracking Number <br /> WASTE MANIFEST Cd:J�7 I1 118w-.2.-9" 1001827314 JJ K <br /> S.Generators Name and Mailing dress Generators Site Address in different than mating address) <br /> Cxn rala�t .Z7�0 lai l(leW.1X'3'( 6 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Evergreen Environmental Services CAD912413252 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> PSC Industrial Outsourcing, Inc. CAROaD0177527 <br /> 8Designated Facility Name and Site Address215t Century, EMI U.S.EPA ID Num bar ; <br /> 2096 Newlands'Drive East <br /> Fernley, NV 39408 <br /> FacmysPhcne: 776-875-2760 <br /> go. 9b.U.S.DOT Deswrition including Proper Shipping Name,Haws Class,ID Number, 10:Cmtaews 11.Total . 12.Unit 13.Waste Codes <br /> -HM and Packing Group(if any)) No. Type. Wangty •ni <br /> Chi <br /> O �. <br /> ILI <br /> ��cru/�lXu lbwif 3S <br /> 3. y-.PGG9 �Owelf ll#j- lPlllbciBPAY <br /> � Z <br /> 4. J <br /> 14.Special Handling Instructions and Additional informal ') <br /> Ayr, e5iii 13"77 <br /> ?R-3- <br /> 16. GENERATOR'810FF OR'S CE KATION: Thereby declare Mat are oanleme olMs mnsignmem are fully and accurately downbed above by the proper shipping name;and ere classified,packaged, <br /> marked and lebelediplecamed,and are in all respects In proper condition for tormil according to applicable international and national govommental regulations.M export shipment and I am the Primary <br /> Elponer,I co"Mel the conteme M this consignment contain to the lemma of the attached EPAAdmowledgment of Consent. - <br /> I cei that the waele minkntratlon statement iderged in 40 CFR 282.27a)(81 am a large quantity general or(C),(81 am a small quay -mane )is true. <br /> GenerelWsl s PH"'Name gnafure Month DeY Yew. <br /> I. t� <br /> 16.Into onal Sh' rib• /` <br /> Impodtol ❑Expel from U.S. Pentry it <br /> Transporter signaWre(for exports only): g U.S.: <br /> Ir 17.TmnspWwAck gmenlof Rsceiplof Matedale 1' <br /> Transporter 1 Pill, <br /> ]VfYW Name Signature Month Day Ywr <br /> renspo r2 'ntedR ed Name store ✓ Month Day- r ' <br /> _ 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> I{ Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) - U.S.FPA ID Number <br /> J � <br /> V <br /> LL Facirty's Phone: <br /> -` Waa 1 S Signature ofABwnato Facility(or Generate) MmnM Day Year ". <br /> 2 <br /> N19.Harardous Waste Report Management Method Cortes(i.e.,codes for hazardous male treatment,disposal,and recycling systems) <br /> 01. 2' 3 4. _ <br /> H ► <br /> 20.Designeted Facility Owner or Operator:Cerfitcation ofrece'ryt ofhazardous materia covered by the mandate except as irkbeld in Item 1 <br /> _ PnnleKll Name Signal C'` x MMoonth ay Year <br /> EPA Form 8700-22(Rem 3-05) Previous editions are obsolete.p4-1-0—O7P03c27 R1111YIPIGNATED FAOILITYTO GENERATOR.STATE(10 REQUIRED). <br /> 10168.0345 <br />