Laserfiche WebLink
Please dnt or type. Fomydesigned for use on elite 12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARD US 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone A.Manifest Tracking Number <br /> WASTE MANIFEST ?4114»4-714-X11,1' 014783146 JJ K <br /> 5.Menerator s Name and Mailing Address Generators Site Address(If different than malling address) <br /> fJ4x�i{r�tRP r':�. <br /> 9Tt7CK1't.'`p):CA i1WjG <br /> Generators Phone: hr <br /> B.Transporter l.Campany Name' " i•:. U.S:EPA ID Number <br /> .�n.A,C4�i;rJf� <br /> 7,Transporter 2 Company Name U.S,EPA ID Number <br /> 8,Designated-Faclily,Name and Silo Address ' <br /> U.S.EPA ID Number <br /> ' l�f+,K�'ft•�{+IEzL i 7tYAlrJ•aFER PIC. <br /> 1627!=,51RbNdAQ.1H trt v1Li:flAtcae.a""Sa. <br /> t3A#�Ft��i)*W r�A.�atl7 . <br /> Fad)isphdnai <br /> 7711 <br /> 80. "B5:U.S:DOTDdiax p1lon onduding Proper&1pping Name Hazard Cless,ID.Nriryiber. ;10.Containets.. , <br /> HM, and Packing Group(if any)) 11:Toter 12,Unit 13.Waste Codes <br /> 1. No. Type. Quantity WtJVoi, <br /> a0 X .1'I;tzARCI0u'3* b'jAm—' 'n17�tC ',City vt7Sbps� 19.51) <br /> lu <br /> :... 1 <br /> 3. I <br /> 14.Special Handling instructions andAddidonal Information .�+• <br /> Rt:#171 P ry r�.� ' t>l - 1J t <br /> t+>EAf�VILOaES !� f <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully end accurately described above by the proper shipping name,aryl are classified,packaged, <br /> marked and labeledlpiacarded,and are In all respects In proper condition for transport according to applicable International and national governmental regulations.If export shipment and tam the Pdmary <br /> Exporter,Ice*that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> 1 certify that the waste minimization statement identified in 40 CFR 262,27(a)Of I am a large qugputy generator)or(b)(III am a small quantity generator)is true, <br /> GeneratorslOfferoes Prin acypeli Name r Signal Month Day Year <br /> ..r 16,international Shipme i <br /> r— Import to U.S. rl from U.S. Port of entry/exit <br /> Transporter signature((Dr exports only): (9;0Date leaving U,S.: <br /> w 17,TranspoderAdmowledgmentofReceipt ofMaterials <br /> Transporter 1 Pdnte&lyped N me , <br /> O r Signa ,, _ Month Day Year <br /> / <br /> Transporter 2Printed/fypedName rSignature Month Day Year <br /> 18.Discrepancy <br /> iBe.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑P.Ual Ra aclion <br /> 1 ❑Full Rejection. <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number. U.S.EPA ID Number <br /> J_ <br /> V <br /> ua Fool ity's Phone:' <br /> 18c.Signature of Ailemale Fadllty(or Generator) Month Day Veor <br /> 19.Hazardous Waste Report Management Method Codas(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> a 1 2. 3. 4. <br /> 20.Designaled Facility(hurter or Operator,Certification of receipt of hazardous materials covered by the manifest except as noted In item lea <br /> Pdntedlfypetl Neme 'r •- Signature /' Month Day ear <br /> i EPA Form 8700:221(146.105) Previous editions are obsolete, TRANSPUR?rrR'S COPY ` <br /> i <br /> I <br /> i <br /> i <br />