Laserfiche WebLink
Fo m Approved.ONIB No 2050.0989 <br /> Please print or type.(Form designed for use on elite 12-pitch)typevaiter.) <br /> UNIFORM HAIAR— 1.Gene2lor ID Num6" 7.pop atof 2 Fm"mh:.y Response Phme 4 Manifest Tracking Number VES <br /> xr <br /> WASTE MANIFEST <br /> 5,Generators Name and Mzi6ng Address Gene-ata•s Site Address Qt direrant than mating adtlress) <br /> a <br /> Generator's Phone US.EPA ID Number <br /> 6.Transporter f C,emarY Nnrn;: <br /> US.EPA ID Mother <br /> 7.Transporter 2 Companyr Name <br /> drk Q. Ad=d7- t`• P __.��_� GB EPAID NL'lll>Er <br /> B.Designated Fedtiy Name and Site Addiess <br /> Faciiit's Phone <br /> 9b.U.S.DOT Description Qrciutlinp&rzper Shippng Puma.Hazard Class.ID Number. 10.Comainers 11.Total 12.Unit 13.Waste Cedes <br /> 90.HM and Packng Group(d onto Na Type Quantity WLNoI <br /> 0 <br /> w 2. <br /> c� <br /> 3. <br /> d <br /> 14 S{euial Month <br /> ny lnsUrrc.tiers and AduFtiunal lnfumomo, <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the exxLLenis of this wnsi9nment are fully and accurately desaibed above by Ne aoper shmDln9 name.and are dassiged,packaged. <br /> marked and labeledlplacanced.and aro in ail respects m Proper condition for Ironsport aWJrding to applicable international and canoral govemmanlal regulators.If export shipment and I am me Primary <br /> Exponer I comfy"A the contents of this mnsignmeel contain to the terms of he atached EPAAckwwlrrdgment of Consent. <br /> I oarify trat the waste mirmuzatan statement idmulind in 49 CFR 262.27(a)(d 1 and a large qua diy generator)or(b)(if I an a small,uaga y generator)is true. Month Day Year <br /> GerieraUtsrOreror's lenat y nip : SigngWre "' i f <br /> „ r <br /> LLL <br /> 16,International Ipmerds ❑Impar to U.S. 0ExPortfrom U.S. polt of entrylex: .... --._...____ --- <br /> Transporter signature(for exports anyt Date leaving U.S.: <br /> w 17.TransporlerAcknadatlpmen!of Receipt of Malerlals _ - 97onlh Oay Year <br /> StgnaWre <br /> � TransPGrtar t PrintedRXP.?d Name - ..- r Ari <br /> g <br /> Signature North Dai. Year <br /> ZTmnsporlur29rmte dad me " � rr–t <br /> i18.Disttepancy <br /> IS,Discrepancy IndlOton Space r—i Quanliry h_�IweResidue ❑Pariah Rejection LJ Ftdl Rojectim <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> iftb.Alternate Fadlily(or Ganeratod <br /> J <br /> V <br /> uQ, Facility's Phone. Month ay Year <br /> W 18c Signature AtemaleFacility aGanembn <br /> Z <br /> 19,HazaN0a9 Waste Report Managemem Metlwd Codes(i.e.,codes for hazardous waste lreabrent,disposal,and recycling systems} 4 <br /> G 2.} 3. <br /> 20 Designared rocky,Owner a Opgrulor Certification of receipt of hazardous matedals covered by the monde except as rated in Mat Month Day ear <br /> Pnnte ITYPed Nark Faure <br /> EPA Fonn�70o-22(Rev.3.05) Previous edltlons are ousolele. DESIGNATED FACILITY TO GENERATOR <br />