Laserfiche WebLink
Phase print or type.(Form designed for use on elite(12-pitch)typewriter, <br /> F- <br /> (UNIFORM HAZARDOUS _ .t �r'4;^ <br /> 1.Generator m Number ) Form Approved.OMfl No.2050-0039 <br /> 2 Page 1 of 3 Emenprlcy Rasporee Ptro <br /> 5.Generators Name and Madln Ad s^--. ,^ � � 4. anrfest Tta <br /> WASTE MANIFEST }t i / .*y _ <br /> C cldRg Number jj�� <br /> 9 dress _ - € 'm ; '. ,' ^.: �e =' �L\ <br /> Generators SBeAddrerf dfferent than maiang address) <br /> •�. ',S•A \gin.'�ti�r'a�� i11... ,l \� \ 1 1 ...' .. <br /> GenerstoesPhone: 4th ,. .` ✓ ` <br /> t-Trnsporter 1 Comparry Name c <br /> U.S.EPA ID Number <br /> i i.TransporterCompany <br /> 4. !�'�f:�' <br /> 2 Com n Name ::,r_—aw.._ v� <br /> y U.S.EPA ID Number r <br /> 8.Des grated Faal y Name and S teAddress <br /> ^��,A t•���•z1;��F,��r.:Tr'� U.S.EPA IDNumber <br /> 1 <br /> R;P.Thi Rs <br /> Facaitys PhormL 01-3-72M, <br /> ga, 9b.U.S.t70TOesaiption fmckrdmg Proper Shipping Name,Hazard Class,ID Number, <br /> 10.ConCa hers <br /> r HM and Packing Group(d any)} 1 t 13.Waste Codes <br /> No. Type QuantityWt/Vol <br /> Re <br /> ,r <br /> w <br /> i ! a. <br /> ii <br /> 1 14.Spedal Handf Q Instructons and Addtional Ir OMkOon <br /> ...�,a...+�,y,... .iY 1.:�� � f� ,�$5._. -s. 56 <br /> t z^�C,,b�...rJG'Lti+� r _ .r.o +•y <br /> r <br /> fl—S ZT-f <br /> y.5 — --� r;7: €'FC17R�`—r <br /> 15. GEKERATOR'SIOFFFROR'S CER nFl.ATION:I hereby declare that the contents of fts 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 govemmental regulations.fFexpert shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the team of the attached EPAAcknowledgment of Consent <br /> I certify that the waste minimization statement identified m 40 CFR 26227(a)(f I am a large quantity generator)or(b)(d I am a small quantity generator)is true. <br /> GeneraterstUfferors PrintedTyped Name Signature r Month Day Year <br /> `t <br /> r 16.International Stupments {—� <br /> Z Ll Import to U.S. ❑Export from U.S. Port of ertrylezit <br /> Transporter signature(for exports only): Data leaving U.S.: <br /> ,17.TransporterAdmovAedgment of Receipt of Materials . <br /> O Transpo ter t <br /> 11rinte,1119ed Name - Skpratirre ;' } ! = mmilhD� YM <br /> j C I <br /> Transporter 2 Prete6lyped Name Signature tt Month Day Year <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space <br /> Q..aY OTypa ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> F 186.Alternate Fadflty(or Generator) U.S.EPA ID Number <br /> U <br /> U- FacifiVs Phone: <br /> 18c.Signature ofAltemate Faaiity(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and recycling systems) <br /> 20.Desgnated Facility Owner or Operator,Certification of receipt of hmB dom materials—ered by the manifest except as noted in Item 18a <br /> IlPrinted(Typed Name { - S gnao re Mar>tr <br /> i '-'-t=i t .,� � f >�•.,~? � �.. ,� �y Year <br /> EPA Forth 870x22(Rev.3-05) Previous editions are obsolete. � r � '~ � '• ` <br /> DESIGNATED FACUTYTO GENERATOR <br />