Laserfiche WebLink
:1--7, = descried for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> 9.Ganerslor u r umbar 2.Page t of 3.Emergemy Response Phone 4.Manifest Tracking Number <br /> `_""`'"'4°° s 000039844 DAT <br /> nto`'E yu.`i:.c"c3T CSS}(_'lrisi S 6 <br /> d� �`', i fc77? F77-2fi9R <br /> --_--Varrg Address Generators Site AtlNess[ifdifferent In an meilig address) <br /> 3"Ai7ifIN 9717,H,pT - <br /> 5300 A ':F-Ri WY <br /> — -_- . OiG i(T�"u PA 95210 12a4Pas 3 412 STCTXR? :1 CA 9--M5 1294)4'^9-4720 <br /> '--:_- -1 Company Natnb U.S,WAIDNumbn � <br /> C� ';t[A!"y' �!^.Vli Oni11En�:S1 Pldl"rc1�G@P.n'c Of Cdil'f0!"nid,, �P CAR500210F117 <br /> -znePbder2Comf✓any erne _ U.S1dVA ONomber <br /> 7asigread Fadlity Name and Site Address U.S.EPA ID Number <br /> -`'3lE09 E4VIROWIT11 <br /> 'kH LOUTH GOE14T ROAD <br /> :0fe3Ph0nW.FRawfi, 175 55135 1520) 310401 .I(0990533259 <br /> 9b.U.S.DOTDawd*n(Including Proper Shipping Name,Hazard Class,ID Number, 10.Conlainers 11.Total 12.Unit 13.Waste Codes .+'t <br /> nl and Packing nota l9 any)) No. Type Duandly WWW. <br /> 1. U91893 €LA:9p;2['_E LIVID, HS M74ROI, 3ENZERE1 3 P611 <br /> kAfR4=101 I-:.__ D19 <br /> if#1253 Pi:'1! R <br /> P <br /> J115 <br /> LAi :ERi i 9IrsrlnE5: 3 Poi: <br /> , T <br /> bmf z)3 <br /> P 90B <br /> 3. <br /> 4. <br /> Special Handing lnsb actions and Additional Information r <br /> tl) TE000320-00 ER611201 BUL4 rM SMETROLEUH 121 000340-91.- ER61127) 2', 81L SASE PAINT, <br /> GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that The contents of tlda consignment am fully and accum ety described above by the proper shipping time,and are desaiAed,packaged, <br /> marked and labeledfptamrded,and are in all respect&In propercandikon forbansport according to applicable international and national governmental regulations.Ifexpodshipmenl and lamthe Primary '1 <br /> Exporter,I certify that the contents of this consignment conform to the tenns of the attached EPAAdnoviledgmentof Consent '^ <br /> loertity that the waste midmizxtion Bodementidentified in 40 CFR 28227(a)(9 ism a large quantity gen (b)(9l am a small quantlty generator)Ia We. <br /> meralnrstO9emrs Printedfiyped Name /-�.,� Signe re Mt& Day Year <br /> .Intemaganel5 ipmenls <br /> LJ how to U.S. Ll Export from U.S. Pod at entrylatdt <br /> anspodersignature(for exports only): Date leaving U.S.: <br /> '^ I <br /> Transporter Acktw'wledgmentof Receipt of Materials <br /> r artPrinledRyped en ,t 3' Mont2h .Dayy� Year <br /> v sl"�� �v.J l✓ y sw. <br /> anspoder 2 PrintedRYped Name Signature Month Day Year <br /> .Discrepancy <br /> a.Discrepancy mdfcafion Space <br /> ❑ Dpangty ❑Type ❑Residue ❑PaMd R6jeWon ❑Full Re(ectiort <br /> Manifest Reference Number: <br /> b.Alternate Facility(or Ganerelar) U.S.EPA ID Number <br /> cilitys Phone: <br /> c.Signature of Alternate Facility(or GeneraWr) Mand Day Year , <br /> .Hazardous Wade Report Management Method Codes(Le.,codes for hazardous wesle treatment disposal,and recycling systems) <br /> 2 3 4 v <br /> .Designated Facility Owner or Operator.Certification of receipt of hazardous maledels covered by the manifest except as need in Item 16a ' <br /> niedlTyped Name Signature Month Day Year <br /> rm 8700-22(Rev.3m) Previous edl ions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />