Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch)typewriter) Farm Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1 Cmrem(nr 10 Numtxfr 2.Page i M 3.Emargenry Response Phone 4.Man l(eeesqt T3,2"'t <br /> ''ryaacId Numbeb 9 R <br /> WASTE MANIFEST tv.A- _so3AfdE.:+ti 1 QU" V f„t 2" 7s lJ.7 a+ <br /> 5.Generators Nam and Mailing Address Genaratpr's Site Address lit different than mailing address) <br /> A:PEK REFRi 't;sE RA'+4GW3 S fr?VtCf q <br /> 1 �(ME:r»!.ASPEft VIAL' <br /> t'wi <br /> Generators Phone:203) !t4G-tip;;="r1C?5 <br /> 8.Transformer 1 Company Name <br /> U.S.EPA ID Number <br /> GALOW82787B <br /> 7.Transporter 2 Company Name IIS.EPA ID Number <br /> 8.Designated Facility Name amt Sile AddressfAh, Yaf:=x �a-�ry <br /> _ U.S.EPA ID Number <br /> sd:F3.ttG <br /> .. sEkdvi.tt."vV 6J4P8 <br /> _ Facild'a Phone: <br /> =L 9a 8b,U.S DOT Desenpdon haefu ling Proper Shipping Name.baud Class,ID Number. ti) Conbiners 11.Total 12.Unit 13.Waste Codes <br /> HM antl Packkg Group(if any): No, Type Quant Wu9d. <br /> 13c2 <br /> *)(744`2'*Rk. 40 AR[)Y:?JS Vt.A"T1 iCst.tt) <br /> z 2 <br /> 2 <br /> RECEIVED <br /> MAR 2 6 2015 <br /> 4, ENVIRONMENTAL. <br /> uGQrTunCDa�;T!U�NT _ ... <br /> 14.$pedal Handling Inamictrns and Additional Information <br /> P"It..E 0446 1106-04 <br /> IWPRO PftIAi'T:.s''a•`.7Tc C'TIVL f_'s.$)Tt-t+tom <br /> SFE Er7G A`i7? Ftd7c17C Eli'„'^'CQP,'f"('.1 kAGIL --0J"11N 441C-1'dAi.t:i <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that his mrasmcs of then consgnmant aro fatly and accurately described above by the Proper,shipping nameand are dessifed,packaged. <br /> marsed and laoelecifdacarded.and are in all respects in proper condition for transport according to applicable international and national ,wommodull nal dabons.It export shipmma and i am the Primary <br /> Exporter,I codify mat the contents of this consignment conform to th terms of the muschad EPAArknowlodgment of Consent. <br /> I certify Ohl the waste rein rabatbn sWtemont avdifiled in did CFR 21 fit I are a targe quarry,generator)or(b)tl I am a small yuannty genemlort Is true. <br /> Genoradrs^loyff�e-rors Pdntedliyped Name 1` P Si9naWre� Mi Day Year <br /> F ye .r ,£ T...P' ✓ �,r, <br /> 16.Intem nal9hignenrs - » ` , <br /> � �lmpmiw 11.5. UExport trod.U4, Po of enirylexil <br /> z Thampomer sgnatum for export only)- Date leaving LLS: <br /> W 17.TransputarAcknouiedgment of Receipt of Materials <br /> Tranaporter1 Printed Typed Name S re Month Day Year <br /> S , r GEM has the appr <br /> I s or, and Will ept DMonth Day Year <br /> Z Tmmprater 2 Prinledll'yW Nmrw e <br /> <� <br /> thA waste th's is <br /> ±8.Discrepancy <br /> fBa.Discrepancylraik'aaon Spam ❑ O�nprY Ipping. ❑Residue ElPuristRejection El Full Rejarirn <br /> hbanifest Reference Number. <br /> +so Aluorahe Facility for Gedrernlorl U.S.EPA.ID Number <br /> W FacrtlYs Phone: <br /> Out 18c.$gnatmeof Ailernale Facilty for Genauu.ri t' Month Day Year <br /> z <br /> � 19.Hazardous Waste Report Management Methotl Cotler(i.fa,abes for hazaMous waste Ireatmenl.disposal,and mcydk+g syshrns) <br /> +_ 8 4 <br /> rr <br /> cNlty Owner or Operator'Cemuticaticn of Weds of hazardous materials cavred by the manifest except as need o Item 18a <br /> w Signature Monts Day Year <br /> EPA Form 87DO-22(Rev 3-05) Previous editions are obsolete. <br /> DESIGNATED FACILITY TO GENERATOR <br />