Laserfiche WebLink
kri+z!for Form Approved.OMB No.209 <br /> NIFORMHAAAMOMMS llGenerator ID Number 2.Page 1 of 3.Emergency Response Phone' 4.MairA t Tracidng Number <br /> T6 MANIFEST o 12 s o 12 0 1) F <br /> 5,Generators Name and Mailing Addma Generators Site Address(if ci ferent than mailing address) <br /> 12"iR Natural PrOt*JCti <br /> as <br /> 12 La#YW Road hlymamirAlcM.com <br /> Generators Pfnone7 _ <br /> 6.Transporter 1 CompanyName U.S.EPA ID Number <br /> AdmvAsd Chemical!Transport Inc./DBA ACTetTury CAROb00"OW <br /> 7.Transporter 2 Company Nance__ U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Adviarcmd 6133 Edith Bhd Chemical NE710r t►rfln►Ti ► IVdID0d22(81U7 <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Wa cte'odes <br /> HM .and Packing Group(if anr)) No. Type Quantity M.Nol. <br /> Ix t.UN3264,Waste Cave liquid.addic,Wmggac,n o.s. pF ]� p 551 02 <br /> 0 X (PhvsPhadc Acid.SWNric Acid),8,PGIt � <br /> W2.UN32$8,Waste Toxic sand,borgardc,n.o.s.(Potasa*= OF 551 11037 <br /> " X Chrramatte),6.1,PGIN p <br /> 3-UN3266,Waste Corrosive birth ,tabic,inargamic,n o.s. y <br /> X (Sodimm�Hydroxide,Potassh m Hydroldde),$,PGO1 DF p 1 [X�I72 <br /> 4'UN3093,Waste Corrosive hqukis,oxkhzW&mo.s.(Perchk is —+ <br /> XAcid,Acetic Ad(1),8(5.1),PGI[ DF p 561 0001 _ <br /> 14.Spatial Handling instructions and Additional Information NlmbV 2W52 Document t D245425 r� <br /> 1)ERG#154; ACT90714 CAA �) $ 3)ERW54; ACTW714 C,Afr- <br /> 2)ERCM51; ACi'rJ9714 CAA-�Ifs-14 f 4)ER134140; ACTW14 CAA IjjE� <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 dassifiec,pzckagea, <br /> marked and Iabetedlplacarded,and are in all respects in proper cwxbm for transport acimnling to applicable intemational and national governmental regulations.If export shipment and I am th.Primary <br /> Exporter,I oertity that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify lhai the waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quantity generator)or(b)(KI am a small quantity generator)is true. <br /> Generator's/Mrors PrintediTyped Name Signature Month Q;y Ye <br /> 16.International Shipments <br /> F— ❑Import to U.S. ❑ U.S. Port of entrylexit: <br /> Z Transporter signature(for exports only}: Data leaving U.S.: <br /> IX W 17.Transporter Admasledgment of Receipt of MaOerlals <br /> T er 1 Priv wyped Name Sig Month Day "ear <br /> o )L� <br /> CL <br /> Z T ritedlTyped Name , _, Month Day Year <br /> 18.Discrepancy <br /> 18a.Discepanty Indication Space ❑ ❑Type ❑Residue ❑Partial Refection ❑Ful Refect on <br /> Manifest Reference Number: _ <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> LL. FacWs Phone: <br /> C31 Be.Signature of Alternate Facility(or Generator) Month Darr Year <br /> a <br /> z <br /> 19.Hazardous Waste Report Management WOW Codes(i.e.,codes for hazardous waste trsatment,disposal,and recycling systems) <br /> � <br /> 1. � 2. 3 �1 4, <br /> 20.Designated Facility Owner or Operator:CertiMation of receipt of hazardous materials covered by the manifastj6ptis notedjq Item 1 <br /> SignMonth C ay Year <br /> EPA <br /> Form 8700.22(Rev.12-17) Previous editions are obsolete. ('DOIGNATED FACILiTYTO GE iFF;E l 1f <br />