Laserfiche WebLink
Form roved. OMB No. 2050-0039 <br /> Please pnntor�pe; (Form designed for`use on*elite.(12-p(lc_t�) {ypewriter.) . APP <br /> UNIFORM HAZARDOUS 1 , GenemtorlD Number 2. Page 1 of 3. Emergency Response Phone 4, M09507909 <br /> Tracking Number <br /> WASTE MANIFEST � � e�. 31707 � / 9Oel - gsy •-99S; 9 FLE . <br /> 5. Generator's Name and Mailing Address derkators site Address (a different than mailing address) <br /> MAcy,peC 6.C4 # 4537(. <br /> Generators Phone: "1 ' r63 5+ &/ I y <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> f v /-j eTI21A i fAJA S c., an, c • R ssG 5 �g <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> 8, Designated Facility Name and Site Address U.S. EPA 10 Number <br /> AA gyoccc.ALLC .. <br /> MAS S . FCT o!t Avg. <br /> Yu11Air /92 . 46536S <br /> Facilit esPhone: A� leGoo se 150 / 0 <br /> ga• 9b. U.S. DOT Description (mcludng Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit <br /> 13. Waste Codes <br /> HM <br /> and Packing Group (d any)) No. Type Quantity W Wol. <br /> 1 . NON R C R/a N 2AROOL4 S - WA STS VOL I lJ <br /> o <br /> C Adsoa�/QICoo) 11000 <br /> w 2. <br /> 3- <br /> 4. <br /> 14. Special Handling Instructions and Additional Information <br /> - �� •93sa �' st:r�+r/ otc. - � �� slo3 � y . SLI , t). •Ixss/. ax.gs�! : - ' . _ . . . , _ . . <br /> 4 ' <br /> 15. GENERATOR'S/OFFEROR'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 t am the Primary <br /> Exporter, I certify that the coolants of this consignment conform to the terms of the attached EPAAtknovrled9man t Consent. <br /> I ty that the waste minimization statement identified in 40 CFR 262.27(a) (if i am a large quantity generator (b) (if t am mall quantity generator) is truce <br /> n Name ' I Big <br /> C [j-f.�� o <br /> IIL <br /> n /en r J+ // <br /> mi 16. International Shipments <br /> i- • -0Import to U.S. 1:1Export from U.S. Port of entry/exit <br /> 2 <br /> Transporter slnature fore rts'on : Date leaving U.S,: <br /> 17. TranspoderAcknowledgment of Receipt of Materials <br /> LU <br /> Transporter 1 Printed/ryped Name on Month L)ay Year <br /> 0 iv <br /> Z Transporter 2 Pdntedrryped Nama gnature on Day ear <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number. <br /> 18b. Alternate Facility (or Generator)- L6.j\q,,0ff%W*PVDhumber <br /> !i aciG s Phone: temS E P <br /> f,8c. Slgneture ofA] ate Facility (or Generator) Month Day . Year , <br /> Z _ <br /> 19. Hazardous Waste Report Management Method Codes (i.e„ codes for hazardous waste treatment, disposal, and recycling systems) <br /> 0 2. 3. 40 <br /> 20. Designated Facility Ovmer.or Operator. Certification of receipt of hazardous matepals covered by the manifest except as noted in Item 18a <br /> PdnledRyped Name Signature Month Day Year <br /> EPA Fom18IM22 (Rev. H5) Previous ediggns are obsolete: ' ` . DE$LGNATED FACII ITY TO GENERATOR ; ' <br />