Laserfiche WebLink
Jan 21 14 12:48p 11ICEI <br /> _ p.2 <br /> � 1� <br /> Pleasc;phrt cr'.vpe.(Form designed foruse on elite(12-p0ch',typewnter.j L Form Appl OMB No.2)1-0-"039 <br /> 11I.GeneratorlDNumaer 2.Paga 1 of 3.F�-gency Response Phcne4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS <br /> WASTE MANIFEST AVIRONME <br /> J J K <br /> 5.Gererator's Name and tdaiiirg Address Generator%iS[oA*l}55(Kc2l'WeW tttan mailing address) <br /> 2encraioes Phone' <br /> 9.Transporter 1 Ccmpany Narre U.S.EPA ID Numter <br /> 1.TransporLr 2 Ccmpany Nacre L.S EPA ID Numter <br /> E Des gnated Fact ity Name and Site Address U.S.EPA ID Numoer <br /> Facil ty's Phone: <br /> 90. 91b.U.S.DOTDespn:ption[Including Prcper Shipping Name,Hazard Gass,ID Number, 10.Containers 11.Tctal 12,Uni <br /> 13 l^rasie Codes <br /> HtA anc Packing Grcup(d any)) No Type Cusnity VA"M <br /> 1. <br /> O <br /> w <br /> z 2. <br /> w <br /> c7 <br /> 14.Special Handring nstructions aid Additicnal Information <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedare that the contents of this ransignment are tiny and accurately described above by the p oper shipping name,and are classified.packaged <br /> ma%ed and labeledlofacarded,and are in.all respects in proper ccndilion'or Uanspar,according to applicable international and national govemmenta',regulatiorS.If export shipment and I am tie Prirw.v <br /> Exporter,I cerfrfy that the cdntants of tFis znsignment conform to the terms d Iha attached-Z?AAckncwtedgme-u of Consent <br /> I certify that the waste minimization statement identiied in 40 CFR 262.21(a)(T I am a large quantity generator)or(b)(f I am a small quantity generator)is true. <br /> Generator'slOfferdrs PrintedlTyped Name Signature Monk Day tear <br /> 16.Intemational Shipments <br /> ❑Import to U.S. ❑Expo,Irom U.S Port of entry/exit <br /> Z Transporter signature(far exports only: Date lowing U.S: <br /> LW17.Transpomr A.knovdecgment of Receipt of Materrals <br /> Li <br /> Transponer 1 Prn'.e67yped Name Signa ire n onti Day Year <br /> O <br /> n <br /> on <br /> Transpo ter 2 Fdnledrryped Name Signature Mont Gay Year <br /> Q <br /> F <br /> 18.Dscrepanay <br /> lea Discrepancy lndcationSoace OL"Ity Tv pe ❑Res idue ❑PartialFaj.Wrl ❑Ful Rejedicr: <br /> Manifest Refe^erce Number <br /> 1So.Allernate Fadrlity(or Generator) U.S EPA ID Number <br /> J <br /> U <br /> LL. Facility's Phone. Mcnth Day Year <br /> w lac.Signature of Arternata Fact ity(or Generator) <br /> r- <br /> Q <br /> M <br /> 0 19.Hazarco:rs haste Report 1Aarag-2nent Method Codes(i.e. codes for hazardous waste treatment,disposal,and recycling systaffs) <br /> W 1 2 3 4. <br /> D <br /> 20,Designated Facility Owner or Oparatnr:CeirUfimbon o'reccioi of hazardous materia:s covered by the manifest except as noted in Item 16a <br /> Pinledrryped Now Signature Month Day Year <br /> ERA r......07nR'M/q— °115) �wviniieorlitiM�areobsolBW_. GENERATOR'S INITIAL COPY <br /> Received Time Jan, 21, 2014 1 : 16PM No, 5048 <br />