Laserfiche WebLink
please print or typelrunii uoa <br />UNIFORM HAZARDOUS <br />WASTE M,4NIFES7 <br />` 5. Generator's Name arild Ma <br />16. Tra <br />;crier 2 Company <br />for use on elite 12-o tch) pr ) _ <br />ienerator 10 Number 2' <br />'f ;4:a <br />Id�ess - <br />r � R !� f •.1'S,'i:' y I'tAt1,-:PR''' :t�'„-t <br />f�l. i.L 1�:.r•. .v <br />i <br />h-:a'I:'<.-:'� "s';•!`r*ii�;::;f:;i`' :i•il:tlf <br />8. Des!gnated;acLity Name and Site.Address € r'J t� Y l t• , 1 ?. ? i.' <br />��..,lt..r-.'tt" '•ror.M:l�.rt, ''`. ;'t�.'rt�-` f i-,:"=. <br />Facilit 's Phone: }"$ f `" -f 3ff�;3 <br />Ga9b. U.S. JOT Descrption (including Proper Shippl g Name, Hazard Class, ID Number. <br />HM and oa king Group (if any)) _ <br />7 <br />2) <br />Specie Handling ',nstn.lctions and Additional VWME wn <br />_Form P. roved. OMB No. 2050-0039 j <br />Manife N <br />3t Tracking u� - l <br />of 3. Emergency Resporzie. Pone "n� 3 JJ K <br />r Yy ( I <br />r� clm ed iris i"rf di8erent than mailing address) <br />J.S. EPA ID Number <br />U 5 EPA iD Number <br />10, Containers 11. Total 1 ^2. Unit. 13.4+taste Codas <br />No. Type Qu41AIi,"Vc..I� <br />t. <br />'1 <br />nment are fully and accurate.. <br />q name, and <br />re classified, <br />15. GENERATOft'bSf�dFFER Red and a eI n all, rte: herI oroper conditire that on for transport according contents of fgto applicable international and national go emmertal regulations, 1 if export shipment and I am the Pa y packaged. <br />mar<ed and a pU of Consent. <br />Exporter, I certify that the contents of this consign ent conform to the terms o fel am attached <br />e Evanncera�or or t firi am a sn al! quantity generator} is !n:e. <br />cenity chat the waste minimization statement Ida fitted in 40 C. R 26_27;aj ( 9 quantity 4e (.) Mont;, Day Year <br />Signature ,,• -� p, <br />erl rater'si Mror's P1.11 ...Typed Name 1 1{ , r <br />46. intetnationa{ Shipments �t ❑Export tom U.S. Port 6i entryiexit• _ <br />L 1 Import to U. Date leaving U.S.: <br />Transporter s gnaturei ifor exports only): <br />17-ranseener Acknowledgment of Receipt of Material Shu Mgr'' Cay Year <br />F <br />Trar�do Printed..?yped me r ”; <br />:w- f .4 5.., 4,f" $ x. ;, vign$ Jay Year <br />`� Signature` <br />18 Discrepancy <br />18a. Discrepancy Indication Space ❑ Quant; ❑ Type ❑Residue <br />Manifest Reference Numb <br />?8h Aaemate Fac!li?} {orGenerator) <br />J <br />v <br />t4i Fecitity's phone: <br />�Q 8c Signature of Aternate Facility la -.,,.,at7rl <br />Z <br />t9. azardous Waste Report Management'Method odes (Le., codes fo, hazardous waste treatment, disposal, and recycling sys!eas} <br />l o ' z. <br />2c. Des;gnated Facility Owner or Operator. Cenifc ion of receipt of hazardous materials covered by the man'fest except as n0sd in Rem 18a <br />Signature <br />Printer;, 'vpec Name <br />FP4 torr-, `1700-22 (Rev 3-05) Previous editions re onSolete <br />Partial Rejection ❑ Full Rejeotion <br />a. <br />Number <br />