Laserfiche WebLink
Please print or type.(Form dell use on elite(12-pitch)typewriter:) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CdA T 4' 14 0 0 2 9 7 3 ` FLC <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Teti <br /> TiT <br /> �A 4"W vat Raid <br /> ires. #I'6 79 traw.:AOWS <br /> Generator's Phone: f2 9" A It Ifs Debbie Irinmr <br /> 6.Transporter 1 Company ame U.S.EPA ID Number <br /> Ittean N otters�reittttne�al�ftr�s k� t,. <br /> 7,Transporter 2 Company Name U.S.EPA 10 Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> i-laaw Hativi %xN Desai UC C A D O 5 9 4 9#31 O <br /> 0 11 <br /> �r titsa. X33 <br /> Facility's Phone: { <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 1 p-Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(If any)) No. Type Quantity Wt.Nol. <br /> 0 1. HOME,Not W.RA Kett f'itol 9 A*#S sz;i Ik i l #%rt Oftl N/A Yeo fi� <br /> d <br /> LU <br /> LU 9 <br /> Z <br /> ua <br /> 0 <br /> 3. - <br /> 4. <br /> 14.Special Handling Instructions and <br /> Additional Information <br /> 3-EZ233674 <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 nallonat 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 EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generato eror's PhntedfTyped Name Signature Morim Day Year <br /> 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of efttrylexit <br /> Transporter signature(for ex its only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> gig <br /> Transporter 1, tedfTypedName Signature ` Month Day <br /> r Yeear <br /> a �3Y t< •'w' et id` ""'✓ c-fir' <br /> ZTransporter 2PrintedfTypedName ignature Month Day Year <br /> d <br /> H <br /> 18.Discrepancy <br /> 18a Discrepancy Indication Space ❑ Quanti <br /> ty El Type El Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> lab.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> 4 <br /> u- Facifi 's Phone: <br /> OL 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> 2 <br /> fig,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1 ` . 2. 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 <br /> nted[Typed Name S' lure Month Day Year <br /> F <br /> EPA Form 8700 2 {Rev.3 05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br /> cleas 111albess bas ttie&"FOF60*!SWAIM'lir and 00 ate"lila►WON itllilt @MNMW ii <br />