Laserfiche WebLink
1 <br /> Please print or type. Fomi Approved.OMB No.2050-0035 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number r <br /> WASTE MANIFEST 000 286 0 1 _ _ 0 13 8 4 2 Q � �� F L E A <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Gulden3;n I.umber <br /> 'A33 S' Zort Way <br /> StocMon,t A 11510 <br /> Generator's Phone: 200-234-7700 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 0k) ::3:4,Enviil=novAa1 CAL000340010 i <br /> 7 Transporter 2 Company Name U.S.EPA ID Number A.t J L O 7 r -' <br /> ANS �4v `3. t7 <br /> 8 Designated Facility game and Site Address U.S EPA ID Numbe, <br /> SS Ecology <br /> ►;i�n,�;trc� 1? miles sotih of <br /> Elle sit11.1 M3 <br /> Facirty•sPhone, 775-553-2203 h1m3J0100 <br /> oa 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Tota; 12.Unit <br /> 13 '•'+'astc Ccdes <br /> HM and Packing Group(d any)) No. Type Quantity WtJVcI. <br /> rY �. jLt I - <br /> �CY1'fYCf Solid (Debris) <br /> Z 2, <br /> � . <br /> - <br /> 3. <br /> 4 <br /> 14.rE5 al Handlin Instructions and Additional Information <br /> 0' S 1 - - ERG 0 171 <br /> Proffs V 070'12K04''51$1 <br /> CMERGENCY CfiMACT JEFF RHODES <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and arc dassdied,packs,ed. <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to app cable intemationaland national governmental regulations.If export shipment and I a r t e Prr,a r <br /> Exporter,I certify that the contents of this consignment conform to the forms of the attached EPAAcknowledgment of Consent. <br /> I ce•tify that the waste minimization statement identified in 40 CFR 262.27(a)(it I am a large quantity generator)or(b)(-dfafm a small quantty generator)is true. <br /> GeneratofslOfferoes Printed/Typed Name ye�natur h'crth C3" <br /> 11E.IntematonalShipmenls — <br /> ❑Import to U.S. ❑Export from U.S. Porto1 entrylexit. <br /> Z Transporter signature(for exports only). Date leaving U.S.: <br /> Ir 17.Transporter AdurovIledgmerd of Receipt of Materials <br /> UJI <br /> Transporter 1 Printedrryped Name �_ 11__ k Signature l j;,' !donor Day year <br /> cc <br /> Z Transporter 2 Printed/Typed Na Signature ',cn:n Day -t.,,• <br /> �1'7 C) r--T L4' A <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type Residue ❑Partial Re ection ,_1 F i'Rers-ton <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> u- Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) V?nth gay <br /> Q 2� <br /> 2 <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and sle <br /> Lu 1. <br /> 20 Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as rioted in Item 18a <br /> Printed/Typed Name 1 Signature Morih Day e <br /> , - <br /> EFA Form 8700.22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />