Laserfiche WebLink
-5 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) or�tr pr 050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tra6kDMJI1urMaZI <br /> WASTE MANIFEST I ciU11111•tr _;, 800-424-4;300-I°(XN 009776971 JJ K <br /> 5 Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> t'0, bow&.16 i-&o Jive retor 1,4o UT3C -10cle �.W*Rd, V4rt11 S of ltwy A <br /> Stnrktnn CA st'.5210i <br /> Generators Phone: 8lr2t3U-3�+7}_t i0 <br /> 6 Transporter 1 Company Name U.S.EPA ID Number <br /> PARC,tipe raltyCxxra4ttxaI., .,: jJ`,' <br /> 7.Transporter Company Name U.S.EPA ID Number <br /> P'SC t_rnnrorrnenta!Seriicesot Pomona-LP <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> tat CenturyCrtvtrorxrrerval%%nagement est N E,IApA, L1..C.- <br /> 119 East Ne411 waft Drive <br /> Eerrdey,NV 89408 <br /> Facility's Phone: 715-575-2160 <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> O 1. UN11Wane,0 <br /> a <br /> w <br /> z 2. <br /> UJ <br /> c� <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> ERGft In order: 115- ERG Book In Cab-Wear appropriate personal protective equipnnerrt:�t, •;; ar UI tig <br /> t( M ypCj <br /> Jotnt 57$3 Cue*:201502005 <br /> 15. GENERATOR'S/OFFEROR'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 national 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 /> Generators/Offeroes Printed/Typed N'r11e Signature I ,-7f Month D@y Yl_ <br /> x)(11 1�j�:. . �:� 1��?�•1�,.,, � (.. �.. �. !t> �..� <br /> -J 16.Intemationai Shipments <br /> z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> - Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name i Signature Month Day Year <br /> a •,l l'1., <br /> ZZ Transporter 2 Printed/Typed Name Signature Month Day Year <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type Residue <br /> yp Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> F- <br /> :-_i 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> ijE Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> CA <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> � <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 /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />