Laserfiche WebLink
Form Approved. OMB No. 2050-0039 <br />Please print or type. (Form designed for use on elite (12 pitch) typewriter.) 4. Manifest Trac Number <br />1. Generator ID Number 2. Page T of 3. Emergency Response Phone 9 <br />UNIFORM HAZARDOUS <br />Ili- 21 : l j. (:�.7 2}tl 1 GL) F <br />WASTE MANIFEST <br />5. Generator's Name and Mailing Address 7 <br />is Generator's Site Address(ifdifferent than mailing address) <br />;'iL lY,Gj t 7t .e15, Lt a. i ill Grocers LT15✓. <br />Ai tltA ?:C z Sl} �TOISP24rrA{ {a3i t1 ii: u�I? ,yfji p iCi", 2 R rats <br />Si"3tii:A Stmt C'onirow3' c (,'a. `7;}{ j:r, 0 cltoc�'s.CIII i'3. � `'3 � <br />Generator's Phone: '+ U.S. EPA ID Number <br />6. Transporter—i Compan"y Name" L_, c;�) t"7 j i <br />an 3cRai�uiri � iter kt - C an cr <br />U.S. EPA ID Number <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />8. Designated Facility�tWane�a*i�q ld {ii- pp� { A 2 <br />+'287 E', 'N La Ling, Parder. C. — 9316^x`8 C {j (ICit}y 1 <br />4 N-0,2461 <br />Facility's Phone: <br />9a 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, No Containers 11. Total 12. Unit 13. Waste Codes <br />HM <br />and Packing Group (if any)) No. Type Quantity Wt.Nol. <br />f P...�.re: S ,t,,,. } .ice:. _ _... _ _ _�__ .. <br />-�'i <br />�. .. .. <br />o .. __ f.1:c��.tici {t��4�;�i C_�a�. �i1�.��;,�'vi? _ .. � <br />� t t <br />UJ 2 <br />Z <br />C7 <br />IE <br />3. <br />J <br />4. �/lf 1rf�L EAS <br />Y., <br />NTr <br />14. Speral HandlingInstructions and Additi nal Inform ti n, _ <br />.y r t.s? ti 31. �f >,� v :i }31 1��sed 0'..J.""fired ()it *Appropriate Personas �'rotetvti� <br />N <br />r Equipmevct <br />15. 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 labeled/placarded, 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 EPAAcknowledgment of Conserrf. <br />I certify that the waste minimization stateme identified in'40 CF 262�7(a) if I am a large quantity generator) or b (if I am a small q amity gen ator) is true. Month Day Year <br />1.$ ' ,K <br />41Gen�nnrternational <br />/Offeror s Printed(Typed Name I / A %F_. <br />51 , <br />�, <br />e- Shipments Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />Date leaving U.S.: <br />Z Transporter sloature (far exports only): <br />LW 17. Transporter Acknowledgment of Receipt of Materials Month Day Year <br />Trans r 1 Printed/Typed Name Signat <br />.� <br />Q Transporter 2 Printed(Typed Name <br />Signature Month Day Year <br />1 <br />F- <br />18. Discrepancy <br />18a. Discrepancy Indication SpaceElType ` ElResidue ❑ Partial Rejection ❑ Full Rejection <br />❑ Quantity <br />Manifest Reference Number: <br />U.S. EPA ID Number <br />18b. Alternate Facility (or Generator) <br />J_ <br />V <br />I Facility's Phone: Month Day Year <br />CS 18c. Signature of Alternate Facility (or Generator) <br />Q <br />Z Hll <br />H 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />11111 I'll <br />O 1 2. <br />3 4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Month Day Year <br />Printedrryped Name Si re e <br />—QD� <br />