Laserfiche WebLink
p type.( 9 ( p )typ is' + t ' , Form A 'roved.OMB No.2050-0039 <br /> Please riot or a Form designed for use on elite 12 itch. ewriter. pP <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Parge 1 of 3 Emergency Response Phsone 7015 <br /> anifest Tracking Number . <br /> WASTE MANIFEST ' . .. 4 8 5 3 JJ.K: <br /> 5.Ge erator's N b Bind,Mailing Address Generator's Site Address(if dlfferent than mailing address) <br /> a i <br /> Generator's Phone: <br /> 6 Transporter 1 Comany,Name° " " U S EPA ID Number <br /> p"SUFY'Yr v. :?§'t+f.U.:{CS4+ 1.,..•4'ti lit?II'itifs' <br /> t <br /> 7.Transporter 2 Company Nam , <br /> / U.S.EP ID Number <br /> +.. Y-�� 1�) i �' t S i� { 'r 4 }r' l � t i <br /> �' <br /> 8 Des Jgnatedlf-at�lii)vlaer�HdeSiteAtldfess tt; U.SEPAIDlumber <br /> AAtu� '°nip <br /> Fact It/.s Phone:' <br /> ga• 9b.U.S.DOT Desorption(Inciuding,Proper Shipping Name,Hazard Class,ID,Number,. :10.Gontalneis:; 11.Totaf;, : 12:Unit 13.Waste Codes <br /> HM. and Packing Group(if any)) No; 11 Type Quantity Wt,Nol. <br /> i <br /> r�'. 1. r�:;C+�;�1,G`'�x,��•ff t^l'd.t,sF }� 7.rtl:? a2,iat t19+'i''3av).,51f3 �, a , <br /> �"! i. ?{1 rr. 7UJ <br /> l <br /> LU <br /> z, <br /> 3. <br /> 4. <br /> 14.Special Handling instructions and Additional Information <br /> k„ <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately descrbed above by the proper shipping name,and are classified,packaged • <br /> marked and labeled/plecarded,and are in all respects in proper condition for transport according to applicable international and national govemmental regulations,if export shipment and I am the Pinmary <br /> I 'porter,I,certlty that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> Ex O( g quantity quantity generator) rue. <br /> certify thatthe waste minimization statement Identified in 40 CFR 262,27 a if I am a large uanti generator)or(b)(if I am.a small uanti enerator Is t <br /> n Yp L Signature —~' Month Day Year <br /> Generators/0fferor s Pd #ed(f ed Name ff 9 f r ¢ , <br /> u 116.Intemational Shipments <br /> F— . ❑Import to U,S. 0 Export from U.S. Port.of enUylexd: <br /> z Transporter signatufe(for exports only): Date leaving U. <br /> rx 17.Transporteocopwiedgment of Receipt of Materials <br /> Tr6nsportei^41 BrJntedlTjrped Name i Signature t f( "" Month ,Day dear, <br /> Off. �� +t' ,, j-... •l °� ' Q <br /> y. <br /> z Trafts�porter2PrintedfrypedName tf Signat red ( 1 t I�h; • ', Month t?aty Y art <br /> 18.Discrepancy <br /> 18a.Discrepancy indication Space JD Quantity ❑Type ❑Residue Partial Rejection ❑full Rejection <br /> Manifest Reference Number: <br /> 18b.Aitemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> taa Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 19.Hazardous Waste Report'Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,aqd recycling systems) <br /> UJ <br /> 1' 2' 3` 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials coveted by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700.22(Rev.3.05) Previous editions are obsolete. TRANSPORTER'S COPY' <br />