Laserfiche WebLink
0L o f 911KP 0219 1115 12 <br /> Please print or type. Form Approved.OMB No.2050-0039 f <br /> UNIFORM HAZARDOUS1.Generator ID Number 2.Page 1 of 3. meg !!p <br /> s o se Phnn�. 4.Manifest Tracking Number <br /> WASTE MANIFEST007314175�I . �. € � ...i '!€ KS <br /> 5.Generators Name and Mailing Address Generator's Site Address(€f different than malling address) <br /> 2,517 W Yosemite pvf� <br /> WAT IF,C r) CA 95W-9641 <br /> is <br /> Generator's Phone: <br /> 6.Trans oder 1 Company Name U.S,EPA ID Number <br /> E-iR'E T1''~ryKt.:.F E N EW Tt fn`s f i'ff; T X R " WI-A5 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address M- AMARM3 S OF t)T•I W I L f OW U.S.EPA ID Number <br /> P500 UjKEIRM ROM-) <br /> USTT('.INWJ't..{,-_OW w <br /> 6`61--76R-620101 ` 6 t� is <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group{if any}} No. Type Quantity Wf.Nol. <br /> 1. <br /> � 11113, UHALIRT � � 1 Cay <br /> 2. <br /> w <br /> 3 <br /> 'i. <br /> 4. <br /> r <br /> L <br /> 14.Special Handling Instructions and Additional Information N815A352E GA 1500 <br /> { <br /> � <br /> 2 a£ �::i :.6 f;�i 3t4�f T� � t r eta in,kOt�a �a r a f l my akuht <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and t am the Primary <br /> Exporter,kedify that the contents of this consignment conform to the terms of the attached EPAAckn6vdedgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262,27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> GeneratorslOfferoes Printedrryped Name Signature Month Day Year <br /> r " j P <br /> J 16.International Shipments <br /> Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of MaterialsLU <br /> z <br /> Transporter 1 Prtntedffyped Name Sna Month Day Year <br /> ! c MF` <br /> Z Trans erg" rinte hyped am'e gnature Month Day Year <br /> p } T. <br /> e.Discrepancy <br /> 18a.Discrepancy Indication Space ly ❑Type ❑ ❑ 1 ❑Full Rejection <br /> ❑ Ouanti T e Residua } Partial Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V II <br /> UFacility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codas for hazardous waste treatment,disposal,and recycling systems) <br /> 20.D signated Fa 'Ii nor or Operator:Cedifealion of receipt hazardous materials covered by the manifest except as noted in Item <br /> PrinledlTypetl mei` Signalure Mo the DPy"`-Year <br /> 1 <br /> EPAForm8 0-22 <br /> 8v.12-17) Previous editions are obsolete. DESIGNATED FA IL )T TO GENERATOR <br />