Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pi.- ,Typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 Tofl. mergency Response Phone 4. nIf st Tracking Number <br /> WASTEMANIFEST C� R00005ry9i g �> 1 a-3r Is ���3'wy 950 F L E_ <br /> 5,Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> "BOO El D"Wo lilreo*, <br /> 2 SAW <br /> CA i <br /> Generator's Phone: f"91 S4%-'29 79 <br /> 6.Transporter 1 Company Name U,S.EPA ID Number <br /> Clear.ar.Hws Ec►4owans ill See vices Irw M A 0 0 -3 9,1 2 2 2 03 0 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Ili an I'ti°VtW S Sim 14#w ILK • re n r :a • �� a s.a n <br /> ; )21 Inti esse RoadiT r►a re;��► <br /> Facihiryi%jngse QA 9513!O(Y a G <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) --— 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> � <br /> 0 X N ,8,. D..UTH)N (%#0U1M,HVC)ROXIM1.8,PG III <br /> Z 2. <br /> W <br /> 14.Special Handling Instructions and Additional Information <br /> 1_��.�r��lr7 ��.3•'�13� �� <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this rrnsignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are is ,II a:s;:sots in proper condition for transport acoorrfing to�pai:cable intamational and national govemmentW.regulations.If export shipment and I am the Primary <br /> Expoa i certify that the contents of this conv!grtr106M oonfnr:,i to the terms of the attached EFAAcknowledgment of Consent. <br /> I: :'..p khat the waste minimization statement identified it 40 CFR 26227(a)(f I am a large quantity generator)or(b)(if I am a small quantity genes ior)is true. <br /> Gener»;o Ali eros nnted ype ame "" "" 311g1ia ure ? _ onff– 'ay– ear <br /> Cw <br /> –.r 16.lotom n.,al Shipments �j <br /> Z ❑In,A%U.S IJ F o:�tram U.S. Portofentry/axi <br /> Iran:r-fes signature(for exports only): Dateleaving U.S.: <br /> W 17.T t psis aer Acknowledgment of Receipt of Materials — <br /> OTransporter 1PPrintedrryped Name Signature - Month Day Year <br /> QTransporter 7 Printed/Typed Name rrg lure opt ay Year <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El Quantity _ ❑Type YP ❑Residue ❑Partial Rejection El Full Rejection <br /> 18b.Alternate Facility(or Generator) "– Manifest Reference Number. <br /> U.S.EPA ID Number <br /> J <br /> U <br /> LL Facili s Phone: <br /> W 18c•Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 05 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G1• y_ 2. 3, 4. <br /> H0 t <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 87060-22(Rev.3-05) Previous editions are obsolete. x c_ GENERATOR'S INITIAL COPY <br /> e3van-"'arbPAA,bag IIh$ eF�{PKSF�RFf q�B f4g'•F��j{g:F81 auS w1P:il tpl Lim 1r aa#the Ajonpt-itt/Rt kc.c4-aniwino <br />