Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number �t �.; r• 2.Pag?1 of 3 Em r e cy Re.p nse Pope 4.Ma ife t T ckrg Numker <br /> WASTE MANIFEST <br /> 1 f 1.,•�tic�{ -� ...�. ,,Ie pe,, �►��W �:��12 FLE <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> QF P i Rd <br /> Yt'i vD•C^l t OT1 CA <br /> Generator's Phone: <br /> 21a'?--460-602 I <br /> 6 Trans orter p U.S.EPA ID Number <br /> SAIR ��5.1aEY to :'' haciq a 'M ")"l 0 ify'";y?G;?:, <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address S� , TSrr:° I , U:P4�dD Number <br /> 4. -2LRCktK <br /> Facility's Phone: <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)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> Y 14l'+ Pci:: ,. �." � <br /> z 2. 1a�l,K h,".('tai Yui"P14 i �(:i�3 E�tia`�'C;,i� t .T6 t '' 1)Lr"1; <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional InformationtzN 18F <br /> Jf <br /> ��f9d9���{{" {"y{��'.��yi"' �^v'p�{+ip�f .{. �ry+�11 [� �y e.� ( �,t.6..[,�y ) �J, �[ r�`;i <br /> r!4 HR I�!`AS-Rt.RC+.i+C 7!'l•..f.7�Y.`Cr'•-•(t,f7Q".17Q 1w�f'M-V L'"_i>�..k.�:N - r�l`138) <br /> 'f "'trl�p s 1 -174 US C{?p ��?t1�:i'+` �:4��t3�:F.1::01 ���i��"I 4147 5., {!•t,� 82.73% 5' f 0a 1 <br /> aK �, kx '�,..,3 r <br /> 15 GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declarethat 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 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 /> Generator's erors Printed/Typed Name bignature ont ay ear <br /> 16.International`Shipments <br /> f- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z :Trans orter signature for exports only): Date leaving U.S.: <br /> W11.Transpor&Acknowledgment of Receipt of Materials•,p <br /> Transporter 1 Pn5edfryped Name ,Y-, Signature * r Month Day Year <br /> CL <br /> A N, <br /> Z Tra6806der 2 Printed/Typed Name Signature Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity El Type El Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> a <br /> LL Facility's Phone: <br /> LOU 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> u, 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 /> Printedfryped Name Signature Month Day Year <br /> EPA Fprrr 870. ;22(f��v.39�P evjpt!s diti, ns, re Qttsolet� r GENERATOR'S INITIAL COPY <br />