Laserfiche WebLink
i <br /> Please print or type.(Form designed for use on eNte 12-pitch)typewdter.) Form Appfovpd.OMSNo.205 A)n <br /> UNIFORM HA7AftDOUB 1 C-©Ganaratorl0 Number 2.Page 1 of 3(.4�Em�rsg�en�y Response Phone f 4.MantloslTracktitg NumWr <br /> WASTE MANIFEST CAC)'k1 d �`6W1 6 8486180 JJK <br /> 5.Generates Nad Maliln�r ss Generators Site Address(fitment than maQing addraas) <br /> '�"`a)6 N& t+ IS Z's-6 'rCav�-rvb <br /> c-c1kj *t tt'f -q?A f "�Y'^-j`•''�, lice t Cly QS tE CZ <br /> Generator's f'hau!tR�A��:E., {`.111'-5 �c <br /> sporler 1 Compo ry Name U S.EPA 10 Number <br /> 7.Trmraporw 2 Company Name U.S,EPA ID Number <br /> &Designated 6�Nam^e and`5� ress <br /> AddArls <br /> U.S.EPA ID Number <br /> Facyi s Phare:l G- <br /> 9a. 9b.U.S..Deaodp600 r7r D (sadtding Proper Shipping Name,Hazard Class,ID Number, 10.Cardalr ars i1.'Ibtal 12.UrA 13,Wash Codes <br /> Hta .and Paddng GmW(If any)} No: Type quenBty WtNd. <br /> Ire 150 <br /> � 2•IJo ry �Q �lti7J'r4�e�� l✓1kZT6� S��:fl � ,�'L j <br /> 41 <br /> 14.Spada)Herm ng kis ructions and Additional In Jon <br /> -)J- 34! 11-k -ovzzz. <br /> 15. SENER'AFOR'8 OREROR'S CERTffiCATION:1 hereby dada tat hie c ontanis of ft ooraqintrent are Tully and w ately daeaibad above byte papa W*hrig rwos,and era diisaifled,packaged, <br /> marked and labeiedlplaoardad,and are in ab raspeda in proper oorda mtfor lransMit acoonding la epgicable InW.m0onal WW neOM0190wrnmentai regufa ws.If WW shlpmeM and 1 am the Pdmary <br /> Exporter,t derdythatlha contents of ft am ignmant coniam b the temw of N atladrad EPAAidaww"mad of Canse>tt. <br /> I c6AIy that the waste mn Inkdon stetemant IdartM in 40 CFR N6-V(v)(h lam a large quantity 9arrarstwj or(b)(If I am a vW quardly 9erwabor)Is true. <br /> GeneratorsMaror's P*tadrf4ped Name Slgnable Monflr Day Year <br /> t;� o P <br /> a 16.I maUanal pmenla ❑Impart 10 U.S. ❑fagroit from U.S. Port of ecdrylerdt: <br /> z TowporiwelgnMra(for worts only): Daho IeaNng U.8: <br /> W 17.Tmn9poltarAti 04@d9meM of Recaptof Mata Wa <br /> Transporter f ypad Name Slgrts Mach Day Yaw <br /> j1 LL <br /> ransporter2 ypedName r / nakna � , <br /> ` l <br /> 1B.Disaepsncy <br /> t8a Dlerrepancy u dlratlon Space ❑ Quwky ❑Type ❑Reft. PafSlsl Rejection ❑Foil 11*6on , <br /> Mardfest Ruferanca Number: ! <br /> 18b.Marnate Facilty(or Gmsrata? US..EPA P Number <br /> i <br /> w Fednys Phone_ <br /> 18c,Signature of Allarnsta F66k(a Generate) Day Year <br /> 19.Hazardous Was4a Report Mene9ernent FAa9idd Codes Q.a;codes for hazardous waste haabaen4 disposal,ao mcirdh9 aysta <br /> 4• <br /> J20,Do*noto�dF*diKy OwnerOr Oparawr Cm9Hmtlon of d or>g rnaterfals amired by tlse menHest except as nded In gem 18a <br /> e Srgnehae Math Year <br /> EPA <br /> Y. 5) PrevausedftlonsSib 6M. A `FACrlCli'YTO DESTINATION STATS(IF REQUIRED) <br />