Laserfiche WebLink
Please print or type. (Form designed for use`on elite (12 -pitch) )pewriter.) Form Approved. OMB No. 2050-0C <br />UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br />WASTE MANIFEST CAI 000 7Q )cly 1 gl.&-7t-5'47 009549008 JJK <br />5. Ge+r�yeratoes a and M ' ij g Add ss {f Generator's Site Address (if different than mailing address) <br />`i <br />f <br />1 <br />Generators Phone: c' i < 1 1 <br />6.' 1 Company Name .S. EPA ID Number <br />F�la#�U-5 EP.t'A'r.CfiiP;tEA:%1. SEk'�iCE:� C. A[Y_AArkC•EEo <br />7. Transporter 2 Company Name EB17 ZUlb U.S. EPA ID Number <br />B. Designated Facility Name and Site Address p n , 1 r ° "'�� ENVIRONMENTAL U.S. EPA ID Number <br />t?.�hiCtS _.1st'•.,RCt1IP.F,)T 3i IT`. GEE;sr'�L?fi�cr <br />3515 3. RATER ROAD HEAITH nFoARTN1cN1'T <br />+EST 'I C.� 1; u . <br />Facility's Phone: 915 37 1 :,747 <br />ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit <br />13. Waste Codes <br />HM <br />and Packing Group (if any)) No. Type Quantity Wt.N01. <br />1 - F-101Q-RCRA. HA yP,OrjLIS bVpSTi ;301-10 ,'rjlLr SOLIDS) Lf 35 <br />Z 2. <br />W <br />i 1 <br />`.�MDLERS Tt! E?E Y1`r�flEi) S%O��'%% r1Ctf2 i'b'V <br />�E° COht'3'R.�..CTi!R: Ft.sa�ly-3-� Ei•f.,.�A-S1vP.3Ei; i =:. _E� ��E <br />-t, 1 t <br />15. GENERATOWSIOFFEROWS CERTIFICATION: I hereby oeclare that the contents of tnis consignment are cony ano accuratery uescnueu auuve uy LI it: prupei ai uppu iy 11411 IV, — 41 ua--Q. pa—you, <br />marked and labelediplacarded, 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 EPAAcknowledgment 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 />Gangator's/Offeror's Printed/Typed Name —Signature ature M�oncth Day <br />16. International Shipments 11 <br />F ❑ Impok to U.S. ❑ Export from U.S. Port of entry/exit: <br />Transporter signature (for exports only). -J Date leaving U.S.: <br />17. Transporter Acknowledgmept of Receipt of Materials <br />Transporter 1 Printed/Typed Nome Signature <br />O <br />IL <br />Z Transporter 2 P' ted/Typed Name Signature <br />� I <br />* 1 18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue <br />Manifest Reference Numt <br />18b. Alternate Facility (or Generator) <br />J_ <br />V <br />Facility's Phone: <br />W 18c. Signature of Alternate Facility (or Generator) <br />Q <br />Z <br />N19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systemsLU ) <br />C 1. 2. 3. <br />/y /1 <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />PrintedrTyped Name Signature <br />i <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. / <br />Yea <br />Yea <br />❑ Partial Rejection U Full Rejection <br />ID Number <br />DESIGNATED FACILITY TO GENERAT( <br />