|
Please print or type.(Form designed for use on elite 12-pitch)typewriter.) ,Form Approved.`6M$.;,hK 05 Q039
<br /> UNIFORM HA?ARDOUS 1,Generator ID Number 2•Page 1 of 3.Emergency Response Phone 741nifest Tracking NumberWASTE MANIFESTa 1,141,E „_ .,, 1+ t t ytrY '`JFK
<br /> 5.Ge Vo
<br /> a Name and Mailing Address Generator's Site Address(if different than mailing address)
<br /> Generator's Phone: '
<br /> 6.Transporter4 Cbmpariy Name U,S,EPA ID Number
<br /> largo"rile;, 1MFt4,1f,}`j'IlY4' _ - - - t°dv(2r,'r"S{Qar.(;h'S•j'; ..
<br /> 7.Transporter 2 Company Name U.S.EPA ID Number
<br /> B.De$19 I��6FdrelifName ad Sri#a Add� s silt, U.S.EPA ID Number
<br /> Facility's Phone:
<br /> go;. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers;; 11.Total- 12;Unit
<br /> HM and Packing Group(If any)) r4 No. Type Quantity Wt.NOI, 11Waste Codes
<br /> 0 �1 t 4' 1 ' 3i.,, / ) !w• .� ^....{t.. .,.�.�b til Il.iti.. 1 't 4 I t l i}L {` r
<br /> Uj
<br /> '�' 9J:yC! f,'t,1+ ivy ,_ ,t�x�f:t. +l l_;r;fl �,.t,r'�• I t �"��� £!
<br /> 2, r l W
<br /> W
<br /> 3.
<br /> 4.
<br /> 14 Spacial Handling Instructions and Additional Information
<br /> ((p
<br /> 15, GENERATOR!$IOFFEROR'S CERTIFICATION: hYrebydeclare thafthe'contents of this consignment are fully and accurately described dab a by the proper shipping 995me,and are classified,packaged,
<br /> marked and.labaletllplaaardetl;antl are in all respects°n proper condition for transport according to applicable Internafiorp I d national govern by regulations,If expbrt shipment and I am the Primary
<br /> Exporter,(•certify at,he contents of this,cohsignmen nform to the terms of the attached EPA Acknowledgment of C n e t. 1
<br /> I'cenity the(,ttjQ waste minimization statement Identifl d n 4 CFR 262.27(a)(If I am a large quantity generator)or(b) rf I am small quantity g pera(or)Is true.
<br /> General s16fferor's Prihtedfl ed Nara $ Signatu ✓'" ! " M4ril4 Day Year
<br /> 44
<br /> 7ZFI,,ntemallonal Shipments,,
<br /> e;
<br /> F— ❑Irrork to Ss' ❑Export from U.S, o of entrylexit•, j
<br /> 11
<br /> Z Transporter signature(for exports only): a leaving U,S.:
<br /> 17.Train porterAcknowletlgment ofReceipt Materials w.;,
<br /> F- Transporter 1 PrintedfTyped Name Signature.
<br /> y Month Day Year,
<br /> d
<br /> Transporter2'Printedfryped Name Signature r Month Day Year
<br /> 18:Discrepancy
<br /> 18a,Discrepancy,lntllcatlon Space Quantity ❑Type ❑Residue
<br /> ❑Partial Rejection' ❑Full Rejection
<br /> Manifest Reference Number:
<br /> 18b,Altemate Facility(or Generator) U.S.EPA ID Number
<br /> J_
<br /> Facility s Phone:
<br /> 18c.Signature of Alternate Facility(or Geherator)' Month Day Year
<br /> Q
<br /> z
<br /> N19:Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems)
<br /> 1. 2. 3. 4.
<br /> 20.Dealgnoted Facility Owner or Operator:Cegtification of receipt of hazardous materials covered by the manifest except as noted In Item 18a
<br />((
<br /> PrIntedfrypeq Name i r.4 r Signatpr �+� r r`;/ Month Day Year
<br /> �� f F
<br /> � X 44
<br /> .3 ��
<br /> +' G''tr�" ly.., ri � d! d {�� (r.•�"- t w c: r( :jrw' ,r! r...� r
<br /> I EPA Form:8700-22(Rev.3.05) Previous editions are obsolete. " 'r TRANSPORTER'S COPY
<br /> L
<br />
|