Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 11.Generator ID Number 2.Page 1 of 3.€mergency, esponse Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST /..��'`:'�) �.fi'4 a ' 1 � gi(xv,, l 014703436 JJ K <br /> 5.Generator's Narqe and Mailing Address7_ <, 'Gertratods Site Address(if different than mailing address) <br /> Geht rra?ors Phone <br /> I <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Desngtedcl�dtrf�Ja�e nd;S�eAddress.,,. U.S.EPA ID Number <br /> 'l:,.M.1�. i'�f�'J,,i.)1�+49t�'4d; _. 'e.�,tt.-.i11 r•{,�1 'i"... <br /> Facillty's Phone <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number , ;10 Containers, 11•Total_r ,12.Unit 13 Waste Codes <br /> HM and Packing Group(if any)) No Type Quantity Wt.Nol. <br /> 7. 1. tt{aitllkt�G4 " tom{.:7i1t��a itb} .ctlfrtC,f2.tt., Lily ?+rt?'C�pisw - fV! <br /> Z 2. <br /> i <br /> 3. <br /> 4. ! <br /> 14.Special Handling Instructions and Additional Information <br /> F t N'M 1 E+ <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 do applicable intemational 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 terns of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.?7(a)(if I am a large quantity generator)qr,(b)(if I`am a small quantity generator)Is true. <br /> Gene for Offer%o.Printedfryped Nam SI natur k p„ -Month Day Year <br /> 1211 <br /> :. <br /> _j 116.International Shipments Import to U.S. ❑Export from <br /> r— p p lS"i Port of entry/exit: <br /> Transporter signature(for exports only); Date leaving U.S.: <br /> w 17.TransporterAcknowledgment of Receipt of Materials <br /> ~ Transporter 1 Printedfryped Name �•-� Si natOte <br /> 0 9 Month Day Year <br /> CL <br /> co <br /> Transporter 2 PdntedrrYPed Name nDDay Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El Quantity ❑Type ❑Residue 0 Partial Rejection ❑Full Reject on <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> a Facility's Phone: <br /> 18c.Signature of Aitemate Facility(or Generator) Month Day Year <br /> Q <br /> z1 <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> W 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 /> Pdntedfryj Signature Mfo�nth Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. TRANSPORTER'S COPY <br /> i <br />