Laserfiche WebLink
Form �< <br /> Please print or type.(Form de' ned for use on ekte(12-pitch typewriter.) R ePtane 4.MarrltestTraekin Number _. <br /> 2 Page t of 3:Emergency 124 <br /> UNIFORM HAZARDOUS 1.Cneretar ID Number ra .E ,7i <br /> WASTE MANIFEST <br /> Generators She Address(d dfffoent than maAing address) <br /> S.Generators Name and Mailing Address4 <br /> 014SORP Ag. Y0^v;xAftT <br /> �F gad <br /> STt-iCFTQP1,CA 9$20F� <br /> Genersto'sPhote: XQ41 i`e - f2 U.S,EPAinNumber <br /> 8.Transpoder 1 Company NBrra 0 +,�1d7Cr49 <br /> (,.Loge W.Lowy,W,- <br /> 7.T <br /> ,-7.Transporter 2 ConPttny mum. N 0 V 2 0 20 15 <br /> U.S.EPA�N�� <br /> INC. <br /> ENVIRONMENTAL <br /> im e.mwWAGI! <br /> q }-rMLD,CA 933,,37 HEALTH DEPARTMENT. <br /> _:. . FHMY <br /> 13.Waste Codes10.Containersi1.Total.> 12.Unk�.U.S.i]OT (rnd�ng Proper Shipping Name,HazardClass.A}I krmber Oua� WWoi..azul PxSdng Group(d any)) <br /> 1. n;L`P2 ft-RA�7.AnR0VLS P*aRS{iw S�3i.tl? ''s5tt?f RttisLni intt4f „i r — <br /> i <br /> 2- <br /> cLLr'� <br /> 3. <br /> 4. <br /> {j i <br /> ti4.Seek- Hwding bistro sand lnfoma+ion iPl ItytP' f , 7 t f 4=P{JF <br /> ERG#In <br /> Q''�Efi.Ft slf�'tj�S <br /> cla <br /> l5. GENERATORSlOFFEROR'S CERTIFICATW N:t hereby declare That the contents of this consignment are fuAy and accnra"described above by the Proper shipping name,and are d I am th packaged. <br /> Acede nation <br /> governmental regula8ors.k export shipment and 1 am the Primary <br /> trnakked and Eabetedlptacorded,and are in aA respects in proper condition for transport acoordk+g to aPP aril of an ,x <br /> Expo.,I certify drat the contents of this consignment conform to Ore terms of the attached FFAAcknmvledgm is hue. <br /> Mon9n Day Year <br /> tcertify that rine waste niauekeinzation sfattxrtert identified in 40 CFR 26'2.27(a)(if 1 am a large quanblY Stgu�a @)(rf I con a small quantity genaato <br /> Generatoes}lofferor's prilrtedlTYPed Nank f <br /> t . <br /> 16.Intemehen�Shipments ❑Export from U.S. Pat of entrAxit <br /> ❑haport to U.S. iitte leaving U.S.: <br /> Z <br /> Transporter signature(for exports anh'): Month DaY Year <br /> 17:Trer oter otReceipt of Materials .Signa um <br /> � Transporter i )ad fame f I t <br /> f,'}. �.`�. Signature Month Day Year <br /> 4 TranspoRer2 Printedffypad Name <br /> 18.Discrepancy . .... . ❑Full Re(edn <br /> Type_ ❑Residue ❑Partial Rajactlon <br /> ilia DiscrepamcY Irrdicatio°Space ❑ Quantity --- ❑ <br /> Manifest Reference Nom' U,S.EPA ID Number <br /> job.Alternate FecAky(or Generator) <br /> Lt Monih Day ear <br /> u4,. Facility's Phone: <br /> 18c.Sigmalure ofAItsMht Fadlity(or Generator) <br /> 'aems <br /> 19.Hazard Waste Report Management Method Codes(.e.,codes for hazardous waste treahcernt disposal,and recycling syst ) 4. <br /> Us 1. j ( { L j 2. <br /> —F j j r Certi5ca8ar of rer�ipt of hazar�us materials covered by the manifest except as m#�pr kern 18a Moth <br /> eal <br /> 20.Designated Facility Owner or Operate• St� 7-, `d ! <br /> priMedlfyped t.r ti (Ji. <br /> �f <br /> -�r'� }•-tet'%f- f . . <br /> ' TRANSPORTERS COP' <br /> EPA Farm 8700-22(Rev.3-05) Orrevious editions are obsolete. <br />