Laserfiche WebLink
.� <br />Form A proved, 0 M No. 2050-0039 <br />:ase. rint or typ®; Form designed for use on Fite (12- Itch) ty ewritbr.r <br />Number 2. Page 1 r>< 3. mergency Response Phone <br />q, M orfs t Trac m u <br />4 4 24' JJ K <br />1. Generator ID <br />UNIFORM HAZARDOUS 7 ai <br />WASTE MANIFEST r, n .. c; <br />Generatofe site dress (if dRarant lhen <br />mailing address) <br />5, pgner5tprs Name and Mailing Address <br />General �}r'91t'rtonei U.S. <br />EPA ID Nu eT <br />6: TraPssdporter Company Name + ps <br />_,•� <br />7.Tra nyName <br />U.S. EPA ID Number <br />B. Designated Faclft Name and Site Address <br />t.'d_�:JtEiift:NfY::fi 'c•t!�V1�'(`�ti (•�'I'�. <br />Al.."WO 1111M <br />NV ��ti r <br />40111 j~at %:� - �1^'4t,; +ir 10, Containers <br />w r Shipping Name, Hazard class, ID Number, <br />DOT D sc ptiafi rricfu u1g tope Type <br />11, Total 12. Unit 13, vyqW Codes <br />Quantity, WLNd. <br />Aa. 9b, U.S. No. <br />HM and Packing Group td any)) <br />1 <br />� 1t 5�!'.. i {Olflt; (r;?i.r`(k �i�l'L•.b�'.� <br />f'AE'4AVhN()tA1.:,el� l� <br />• 2. <br />.• <br />14, S�� Hand r s• n•, <br />� I' <br />( r. <br />the proper lig re ified, packaged, <br />Hbonall and nabondf 9 remme ytzf rz9�aOn3•'f� rt eNpmsnt ndalam the Primary <br />GENE RATOR'S fGPFEROR'S CERTIFICATION: I t ersby d er <br />15, <br />gand'RI n for transportaccordng to apP.ble <br />marked and labeledlplacarded, and are in all raspscss in prop _ <br />— <br />Exporter, I certify that the contents of thls consignment contorm to the terms of the attached EPAAcknowlae neer b C f I a m` small eneratoT) is VA. <br />Exporter,I large g ) ( ( � qu ear <br />artily that the wash minimizer on statement identMed in 40 CFR 262.27(a) (if am a quart* <br />'� <br />Sign�4rre ` i j <br />i ± 4 Day <br />�y ^•, <br />Ganeratorel0>terors Prtn=liyped ! <br />ro !,„1; j <br />6. Inlern on Ipmeri s '' Import to U.S. ❑Export from U.5. Port of entrylaxit: <br />Data leaving U.S: <br />v <br />z Transporter signature (for exports only) <br />17. Transporter Ad nONIOdgment of Receipt of Materials signs re <br />Ma th Day Year <br />Transporters ted(lypedName <br />r <br />Month Day Year <br />i t signature <br />Transporter 2 P nl pod Narrie <br />18. Discrepancyrr�� 1I ! <br />Residue <br />❑ LJ .. 1 <br />i <br />❑ Partial Rejection ❑ Full Rejacrion <br />tea. Discrepancy Indication Space ❑ C r,,ga <br />Manifest Reference Number: <br />Us. EPA ID Number <br />�. 1 Bb. Alternate F 01111 (or Generator) <br />J <br />Ca <br />Phone: <br />Men Day Year <br />Fakaliys <br />c. SignW a re of temats Fac I (or eneratrr) <br />CD 1 g Hazardous Waste Report Mansgome0t Method Codes (ie., cedes for hazardous wa6ce aeatmant dlsp3sal, and raycfing systems) <br />4 <br />covered by the <br />manifest except es noted in Itsin 1 Da <br />ear <br />20. Designated FaeilNy Owner or Operator. Ceraflcation of receipt of hazardous mafariais <br />5!gna re <br />o ay <br />a- <br />nnted pe Name <br />GENERATOR'S INITIAL COPY <br />EPA Form 9700 22 (Rev. 3-D5) Previous editions are obsolete. <br />LO 'd L 1; :5 L O LOZ EZ Int O 161991 60Z XEd <br />10d 34 NVA <br />