Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
1 <br /> Please print or type , (Form designed for use on elite ( 12•pltch) typewriter.) Form Approved , OMB No. 2050.0039 <br /> II <br /> UNIFORM HAZARDOUS 1 . Generator ID Number 12o Page t of 1 3. Emergency Response Phone 4. Manifest Tracking Numbor <br /> WASTE MANIFEST C A 8 0 0 0 0 73585 i. 017 4 6 8 9 4 6 JJ K <br /> 5. Generalor's Name and Mailing Address Generator's Site Address (if different than mailing address) <br /> i 4 It I''I11fit l : i : i'it ! <br /> ?fi:1U 1`It.1Nl H IVis,t.; ! . t. }: fiUi'd ) <br /> 'i RACY t;ia s <br /> Generators Phone: 20`0) ti�i%t :L_I. t. :L <br /> 6. Transporter 1 Company Name <br /> U .S. EPA ID Numbar <br /> WUR [01) UILe I: NVII•; UNNI [ I,) I � L :iL: IiVIG I r . . U . <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> 14' ul � t. I rVifllll': ht ; Gl ' VI�f�Y' ,Yci'I' GiV! IIVC. . C it t ; t.) Uki) 4 7 ;; <br /> B. Designated Facility Name and Site Addross U.S. EPA ID Number <br /> YUNIA YES LL(; <br /> :? 730EIF'J II >) i <br /> IFFac lity's 0;-one: <br /> Ja 9b, U.S. DOT Description ( including Proper Shipp;ng Name, Hazard Claas. ID Number, 10. t;cntairers ' t 13 Waste Codes <br /> hryl and Packing Group (it any)) No type �i tit "— <br /> ar 1I\ UI�- I Zfiti/i 1 '111::.�ti� L)t� UJ bUi1� I t'. . :�tat,ll ( Oln �iOt . l L) q IIAI ' 1-. li PILI L_ I% �i6) ra. - - <br /> O , <br /> Z 2 . <br /> W i <br /> t7 <br /> 3 <br /> 4. <br /> F k7 <br /> 14 , Special Handling Instructions and Additional Information lie. ?I <br /> E lAFRONI: NGY CON ' 1 i1t :'I Il . ldil .i. Pit ; ! <br /> OIt..YSC) LIU Niif' l . 1 111 I ' i ;� ' I ' . ( ! 1111 I ' I � � U c <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contel;ts of Oris consignment aro fully nmol a cweusly described abova by the pnmr <br /> )per shipping m � . , aril tyre classified , packaged , <br /> marked and labeledtplacarded . and are in all respects m proper eonoition for transport according IF <br /> to applicable internatiinal and nationai gavernmenial regulations, n export shipment and I am the Primary <br /> E ExImder, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowlodgment of Consent. <br /> 1 certify that the waste minimization statement identified in 40 CFR 262.27(x) (if I am a large quantity generator) or (b) (if I am a small quantity generator} is true. <br /> IIIII <br /> Generetorsiofferors Prinledrr ud Name <br /> Signature Month Day Yety <br /> fa <br /> � 16. International Shipments rr II c. _, ! i ; ( -Pot <br /> ❑ Import to U .S . L� Export from U .S . r — — — <br /> zTransporter signature (for exports only): Data leaving us . <br /> K 17. TransporterAcknowledgmeni of Re+Mlpl of Materials _ <br /> Trans- ter 1 Printed/Typed Name Sighalun, -• Month Day Yt:ar <br /> a Tran ort 2 777 <br /> rime (y a Nama /� / grutiuref D �_ — �dgt1`h Oay _ YQtu <br /> 18. Discrepancy <br /> 1@a. Discrepancy Indication Space ❑ ouantity ^� type — � fGsi iue Partial Rejection _ Full Rejucti ,r,. <br /> t,lanifest Ryfr: retI +' t`umbur . T_--- <br /> 18b. Alternate Facility (or Generator) ^�^ `'S EPA II) hli: i <br /> ..r <br /> V <br /> W Facillly's Phone: <br /> oth Day Year <br /> W 18c. Signature of Alternate Facility (ur Generator) <br /> D <br /> a <br /> x <br /> N19. Hazardous Waste Report Management Method Codas (i.u., codes for hazardous waste tret+Nnunt disposal , and recycl;ry syslerns) <br /> 0 1 241 3 4 <br /> ul I - I j <br /> 20, Designated Facility dwrier or Operator. Certification of receipt of hazardous hia'wials covered tj the manifest yx.rN% as naed m rain torr _ <br /> PrmtecUTyp me Signor re. PAunth Day Year <br /> Gob <br /> EPA Form 870 •22 (Rev. 3.05) Previous ed ons are o soete. } ; k�! TJJGIVP+i'I i:} I'rf! =,9 ,f`0'Y ' i ' 17L i '11VI1i 11J1\1 Foi�1� ( It= Cif :U !) Itttil , ) <br /> a <br />