Laserfiche WebLink
sn - lso� �33 <br /> Plea$e'print or.b".(Form design edtoQse on alb(12-pitch)Aypewriter.) - Form Approved.OMB No.2050-D039 <br /> UNIFORM HAZARDOUS 1.GeneratoQD Number 4 r 2 Page 1 of 3 Emergency Response Phone 4 Manffest7mcpkbrg Numbeerr�� <br /> WASTE MANIFEST !✓ " ; -,.,ZX' 0.1 Q 8 7r�';L o 4 JJK <br /> 5.Generator's Na ntoy3 <br /> d Ma'Ina Address -G mrSite Address(d ddferent than mailing address) <br /> 5 w�v� �LZL sr ,G <br /> � ' <br /> ;5rendra&s Phone <br /> 6Transporterl'Company Name v_... U.S EPA ID Number <br /> C� 003 1. <br /> 7.Transporter 2 Company Nanfe U: . A Number ' <br /> B D ignatee Facility Nam and Site dress - qA�� U.S.EPA ID Number <br /> k o ✓ o <br /> EFadlity'_Phone . : "i�:. CAO 0 .. 31 V <br /> '9a 9;iU.S:DD Description(mciu mg Proper Shipping Na azad Class,ID Number, 10.Containers 11,Total 12.Unit <br /> HIM and Paddng Group(A any)) :. _ No. Type Quantity W Wol. 13.Waste Codes <br /> y i73Y ;l <br /> l�- <br /> SQ�Y � i 33 <br /> 4. N 3077 , ,,�,rdov, Wes fl ` , PA l <br /> 4 Special Handling I ns aid Additionayl �ra <br /> ltr�rt.,(S,W51077L� lerc�y �ti' i� r� X57►lrgldN <br /> } 1 'KrGFAERATOR'SIOFFERORS'LERTIFlCATION::1 Aaieby dedare Mat ba contents of Mrs consignment are Nlty and accurately desrnbed above by the pmpershippngname,and am classified packaged, <br /> 'mar(Ced end.Iabelediplararded,and are In all respects in proper condition far transport according to applicable intemationaland national govemmental regulations.If export shipment and Ism the Pmay <br /> Exporter,I codify that the contents of this consignment conform to the terms of the attached EPAAdmowledgmem of Consent <br /> I certify that the waste minim@ation statement identified in 40 CFR 262.27(a)(it I am a large quantity generator)or(b)(d1 am a small quantity generator):¢bus. _ <br /> 'GenwatofslDBemfs Printeiflyped Name Sigmature Monts —Ni—y- <br /> -1 <br /> ayYearJ 16 IntemationalShipmenls - .- <br /> ❑Importb U.S. -� �❑5ghod hom U.S— Port of enhylehrit: _ <br /> a, ransporter siggaWre(far ehipor'k'\only); - Date leaving U.S.: <br /> w' 17,7ransporter4amowleogmentof Receipt of Materials - <br /> Transporter 1 Pentad? Name. signature Monts Day Year <br /> CL, <br /> - ..'.. _1/0 f.A <br /> 'Z 7mnsporter2PrintedlFyped'Name Sign Month Day Year <br /> Pa El Quantity []Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Mand% R e E I_'.tl <br /> 181h.Alternate Facility,(or Generator) -. U.S EPA ID Number <br /> MAY o � 2017 <br /> tai Facrfih/sPhone: <br /> w �8c•SignaWni afAltemale Facr7ity(or Generator) - ) Me* Day Year <br /> EWMIONM£P(iALH. A fit! <br /> -19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste hestmem,disposal,and recydMg systems) <br /> 1. 2 - 3. 4. <br /> &DesignatedFacridy Owneror Operemr.Cemfiratioa ofrera'rytafhazardous malenals covered by4ha magj[esl e-.Wasnotad in Item 18a <br /> PnnledRyped Name <br /> Signature Monts Day Year <br />