Laserfiche WebLink
Pkaasa print or type.(Farm designed for use on elite(12-pitch)typewriter.) -- <br /> Foam Approved.OMB No.2050-0039 <br /> UNIFORMHAZAR000S 1.Genereau 10 Number 2Pageioi 3Fmergancy Reslearl9e Pimm; <br /> 4.Modified freaking Number s VES <br /> WASTE MANIFEST '- r"hI`a <br /> 5.Generators Name and Mahng Address Gerwram s Ste Addr<_as(r ddha:ent teal marling atldress) <br /> y.A T- <br /> ��_6 <br /> Generators Phone. US EPA ID Numher <br /> E TrmspMerCompany Nam' <br /> :1 S-EPA ID Number <br /> 7,T-dnemwter2 Company Nane <br /> {;s.,}� x"'i+ JS EPAIDNnnber <br /> r.Designated Facility Nanro and SlleAddresa <br /> Facility's Plmne: <br /> 11.Total 12.Unit <br /> ya, 9b.US.DOT Dascnpem linaluding Prexr ShiP?ing Name,Hmzurtl Class.lO Number, 10,Containers DaanNY WtNol. Li.WasleCNea <br /> HM and-dckmq Group(if any)) No. Type <br /> P (' <br /> a 2. <br /> w <br /> cn <br /> 3 <br /> 4. <br /> 14 special Handling to drudlers war Additional Informatlon <br /> +5. GENERATOR'SIOfFEROR'S CERTIFICA710N: I hereby declare thatths contents of this mnsignment ere fully and wouretetg ipmedescribed above by the proper shipping name, are des m th packaged, <br /> marked and Iabeiad'piegenad,and wad at respects in proper condition for transport according to applicable international and national governmental rogulations.If export shnt and I am Ne Priori <br /> Exporter,I codify that the contents of this eu sigumem contend to the are,of the attached EPA Acknowledgment of Consent. <br /> Im(Try that the waste minimization statement identified'n 40 CFR 282.27(a)(d I am a large quantity generator)or(m(if I am a small quantly generator)is true, Month Day Year <br /> Sly ahrre <br /> GeneratorHOgerors PmnmOTyped Name I�! <br /> � 16 ln:ematlma 5humenis� ' Expod team U.S. - Pon of entryaxd _....._._. ........ <br /> r�? _........_ <br /> T„ t lirnpnrt loch S. Dare removing U.S.: <br /> S Trensyoner sgratme liar exports only}. <br /> 17.Transporter Adm Wedgmentof Realist of Maermis Month Day Year <br /> s" Transporter 1Pf10lodiTYped Name Signa ure f .,,t ,. "fi t s. <br /> � e{ '` E CP <br /> Sign re Monty Day Year <br /> 6 Transporter 2 PrimediTyPed Name ,..�. <br /> 18.Disaropanoy <br /> 18a.Discrepancy Indication Space D cowboy ❑Resdue ❑Partial Rejection ❑Full Rejected <br /> Manifest Reference Number: <br /> U.S.EPAID Number <br /> 18b.Alter eto Facility nor Generator <br /> J <br /> V <br /> uQ. fadlity's Phone. - 7,—,-6Day Year <br /> w 18c.Signature otAttemale Pacildy(or Generator) <br /> a <br /> Z <br /> o—i 19.Hazardous Waste Repel MenagemaM Matlaod Codes'i e.,rales for hazallous waste treatment,disposal,and recycfng systems! <br /> to 1. 2. 3. 4. <br /> 0 <br /> 20DesgnaWd Facility Owner of operator:Certificated of receipt of larcenous materials covered by Ne maddest except as noted in cam His h,'cnrL Day ear <br /> I SrcNraiure. <br /> Pnplad/ryped Nacos <br /> DESIGNATED FACILITY TO GENERATOR <br /> EPA Form 0700-22(Rev.3-05) Previous edillons are obsolete. <br />