Laserfiche WebLink
x,. <br /> Please print or .(Form designed for use on elite 12-pitch 1y36wdtac) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST '.. AI..;J..�•k.' f�'t 2'-1".:.� 1 ::11;x..`;'1-i,"<' 01560830 JJK <br /> 5.Generators NiRe andrMailing Address Generators Site Address(If di ferenr than mailing address) <br /> .1y'Y�.y�. �U4..T+ 3.. �e qty h..P• _ `;: <br /> >r Gion mbes Pham <br /> 6.Transporter l Company Name ,." 1 U.S.EPA ID Number <br /> Eihh;N°;1i'dG;F:eB'•s.3EFe,+)LE"v Ii s:-%Sl'A406y. <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 6.Designated Fadi Name and Site Address U.S.EPA ID Number <br /> g M U.S. <br /> Fadliys Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Carmines 11.Tocol 12.Unit 13.Waste Codes <br /> HM and Packing Group if any)) No. Type Quantity WWob <br /> 1. <br /> Of <br /> O <br /> w <br /> z 2. <br /> w <br /> 3. <br /> 4, <br /> 14.Special Handling Instructions andAddficaml Intonnation <br /> f"�!r47lFPc Yr.FIE'-IF;114[97 ..{rip,r'-e :_;err;`Mr__T)"c'6&7 <br /> :z F+ CngiT%.A.TOfr"' i'ar r Z"•el'•"< -fc:FTf%-{. Y+i°'9Sai`1: <br /> 15. GENFAATOR'SIDFFEROR'S CERTIFICATION: I hereby declare Vast the contemn ofthb consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and mbeletYptecarded,and are in all manses In pmper condition fartrivsport according to applicable International and rational governmental regulations.if a poshIpment and I an the Primary <br /> Exporter.I caNry grant her commrim of this consignment conform to the terms of the attached EPAMlmowledgrnent of Consent <br /> I certify Vast the waste minimization statement IdenitlAed In 40 CFR 282.27(a)of I sm a large quantity generator)or(b)(di am a arell quantity generator)Is true. <br /> Georetord08erora Printed(Typed Name Signature Month Day Year, <br /> J 16.International Shipments .r <br /> F- ❑Impatto U.S. El Dow from u-s. Pod ofentrylexi[ <br /> z - <br /> Transporter signature(kr experts only): Data mawrg U.S.: <br /> W 17.TrensporerAdmowledgmentofReceipt of Materials <br /> Transporter 1 PrintedTyped Name Signature r Month Day Year <br /> O .3. r... <br /> Transporter 2 PrintedTyped Name Signature - McrM Day year <br /> y 18.Discrepancy <br /> 18a.Discrepancy Indication Spam ❑ Quantity ❑Type ❑ReeMue <br /> ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Fa ay(a Generator) U.S.EPA ID Number <br /> J <br /> U <br /> u Facility's Phone: <br /> a 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 2 <br /> 19,Hazardous Waste Report Management Method Codes(i.e.,codes for haiallous Baste treatment,dmpoi and recyding systems) <br /> 1, 2. 3. 4. <br /> 20,Designated Facility Darner cr Operator:Certification of receipt of hazardous me(earna covered by the mandest except as riled M Item 18a <br /> 1 PmtedfTyped Name Signature Month Day Year <br /> EPA Form 870022(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />