Laserfiche WebLink
Please print or type. (Form designed for use on elite (12 -pitch writer.) <br />Form Aooroved. OMB No 2050-0039 <br />trA t-orm UIUU-ZZ (Kev. 3-U5) Nrevious editions are obsolete. ' DESa'IGNATE6 FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS <br />1 •Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />1(800) 24.9300 <br />" .A <br />JJK- <br />5. Generator's Name and Mailing AddressGenerator's Site Address (if different than mailing address) <br />ICHE f (w.ON TRUC It# -44-- it 1,:"d`0N <br />PO BOX JEKXr2 A T4 f. # If t= �,,AN,4 I (: ,ES' T CIRCLE <br />, <br />Generator's Phone: 16 1,031-113726 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Ngame and Site Address U.S. EPA ID Number <br />KNEW `' <br />pl4a�i'r4D�.}�:.� <br />2U ' °r60 1 �1 <br />$$''7g" <br />CONIFON <br />Facility's Phone: €' 'I° � + .g°i( € C A T ej 8 0 0 L 3 3 <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />13. Waste Codes <br />No. <br />Type <br />1. <br />® <br />NON...RAORA -!,V,Iq[_cd..'0 X'zTE LI' -.'Jt`) 4 .O.."` Ar!�R,I <br />•a. <br />001 <br />1' <br />G. <br />w <br />C? <br />3. <br />FOR RECYCLING/TREATMENT AT THE <br />DeMENNO/KERDOON FACILITY IN COMPTON, <br />4. <br />PERMITS TO RECEIVE YOUR WASTE STREAM AS <br />ii! 1J <br />14. Special Handling Instructions and Additional Information <br />iAERGP`i1 'PYC"FLE 61 . iLWATER*APR RIAJE PEP OVALPROTECTIVE g P <br />N <br />PROJI mefi PCdd008' <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 labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment 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 />Generatoes/Offeroes PrintedfFyped Name Signature Month Day Year <br />MILL <br />..� <br />-r <br />r-- <br />16. International Shipments <br />1:1Import to U.S. ❑ Export from U.S. Port of entrylexi . <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials <br />tK <br />Transporter 1 Pdntedfryped Name Signature Month Day Year <br />d <br />N <br />f <br />4 <br />Q <br />Transporte 2 rinted/Typed Name ature G°` Month Day Year <br />h <br />18. Discrepancy <br />18a. Discrepancy Indication Space <br />Quantity ❑Type 1:1 Residue El Partial Rejection El Full Rejection <br />, <br />P�, 1 <br />cIlCd IrIa�B It�/@th fes1 Re Of � <br />18b. Alternate Facili or Generator -" -- --- ' """ <br />. _ .... _ ty � ) U.S. EPA ID Number <br />J_ <br />V <br />Facility's Phone: <br />W <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />Q <br />Z <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />® <br />1. 2 <br />2. <br />3. <br />4. <br />20. Design ted Facility Owner or 0 erator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />PrtCted/T ed Name Signature k - - MonthDay Year <br />.if <br />�C-, _ , <br />AL <br />trA t-orm UIUU-ZZ (Kev. 3-U5) Nrevious editions are obsolete. ' DESa'IGNATE6 FACILITY TO GENERATOR <br />