Laserfiche WebLink
�u <br /> 07 vk' <br /> Form Approved.OMB No.2050-0039 <br /> %pose print or type.(Form designed for use an elite(12 pitch t Swollen.Generator <br /> HAZARDOUS 0 <br /> i.Generator IU Number 2 Pa9�P t of 3.Emelgenq Rsspnnse Phone 4.Manifest Tracking Number <br /> 0543499 VES- <br /> WASTE <br /> MANIFEST , <br /> 5. Generator's S to Address(if different than mailing address) <br /> Genemtofs Name and Mailing Addresa <br /> Genewors'hcne US.EPA ID NumMr <br /> t rn•apnAar�Co 4n ,i`unb <br /> US EPAID Number <br /> 7.Transporter 2 Cohnpany Nome <br /> ,M EIy If'• .T. <br /> US.EPAID NOlnbel <br /> B.Dinufmahed Facility Name and Site Adores- <br /> ±22210 <br /> dores h - <br /> r <br /> Faalk'a Phomt ro <br /> 10.Containers 11.7o1a1 12.Unit ig.waste Codes <br /> 9,. So.U.S.DOT DescdplOn(including Proper Snipping Namo.Hazard pass.IG Number, No Type Quantity WLNM. <br /> HM aid Packing Group(d any)) <br /> C <br /> 0 <br /> w <br /> z s <br /> w ,q <br /> a. <br /> a <br /> 14 Special Heiden)hi$t"LIVIS la and Additional in(OnnahOn <br /> 15. GENERATOR'SIOFFEROR'SCERTIFICATION: Thereby declare that Me contents of phismnskAnmantam holy and and <br /> entl egropers,it"Pname.areared I amthepackaged• <br /> marked and laboledlplauMed,and are in an respects in proper condition for transport according to applicable indentationslend nations)governmental regulations,it capon shipment and am the Primary <br /> Exporter.I cernfy that the contents of this consignment conform to the tams at the aaachad EPA Acknowledgment of COnaanl. <br /> I canary that me waste Rom zaticn statement Identified in 40 CFR 262.27(a)0t I am a 18190 quantity generator)or M(01 m e small ghmm h tor)is We_ Monty Day Year <br /> Sigtl ,4fa l� , q �/' <br /> Genera-roprsf0$ Pnnte�d/ff'�Pe Name �, lvw, <br /> 16.Inremalional Shipments Import to U.S. El Export from U S. Pat Ofentryyexit'. ..._._.. -_-. <br /> Date leaving U.S.: <br /> Transporter signature(tor exports only): <br /> W 17.Transporter Acknowledgmant Of ReceiPI of Meredak Martin Day Year <br /> Transporter)PmredlTyped Nam 55natdre <br /> S9natwe Month Day Yser <br /> Twi sporeir 2 PnntetlRy roJ%Ile <br /> 18 Discrepancy II--11 <br /> 1Ba.Discrepancy indication Space ❑Type LJ Residue Partial Rejection Fall Rejection Quantity <br /> Manifest Reference Number. <br /> U.S.EPA IO Number <br /> 18),Alremate Fadfly(or Generator) <br /> J <br /> U <br /> Facility's Phone: earl Day Year <br /> W i8r..Signabire nfAlternatO Facility lar Cwneratnrl <br /> Y <br /> 19.Hazard s Waste Ripon Management Method Codes i.e.codes fa hazardous waste Ireaiment disposal.and recycling systems) 4 <br /> p( 7 <br /> Ica i2 „r,.A <br /> 20 Cesegna Fadity0ooher or Operator:Cer6fihxbon ofeecepl hazardaos materials covered by themandest excaptas noted In llem We ly ea. <br /> Ign e <br /> PnntectTyped NEM ;.,..d a` 'e t'L.j' G , (. y ,j.;, , <br /> DESIGNATED WILITYTOGENERATOR <br /> EPAFo1m8700.22( 8¢'3-05) PredOuseditionsare0bsolete. <br />