Laserfiche WebLink
Please print or type (Form desrgrled for use on elite(12-pitch)typewriter) Form Appto-,t r.OMB`,o 2050.003? <br /> UNIFORM HAZARDOUS I.Genera'.or lD Number2 Page i of 3 F_mergenry Response Phone 4.Maning Number <br /> ifest Track <br /> WASTE MANIFEST . . J J K <br /> 5 Ge-eratces Name and Afailirsg Address Gereratals Ste Address d d'erent than rnarrg adds w.s <br /> c s Phcre. <br /> sPc^cr 1 C.-'Dry Na-e US EPA D Number <br /> 7 Trarsporter 2 Company Name U.S.EPA 1D Number <br /> 8 Dented Facility Name and Site Address <br /> US EPA[D Number <br /> Facirtys Phone: <br /> ga. 5b-U.S DOT Desmption findLicixg Proper 5t•„ppirtg Name,Hazard Class,ID Number to.Container 11 TO 13.1 12 Uni <br /> HM and Packing Group(if any)) No Type Ouantty ylwol 13 Waste Codes <br /> Q <br /> z 2. <br /> LU <br /> Q <br /> 3. <br /> 4- <br /> $4 ScecW Handling Instnrctions and Additional Information <br /> 15. GENERATOR'SrOFPEROR'S CERTIFICATION:I hereby dedam that the contents of M consignment are fuly and accurately described above by the proper shipping name and are classified.packaged. <br /> marked and labek'dlplamrled,and are In all respects in proper condition far transport according to appliimble international and national govemmentat regilatiens N export shipment and I am the Prima <br /> Exporter.I certify Ihet the contents of this consignment conform to the lerms of the aaached FPA Aclsnasvkdgntenl of Cansenl ry <br /> I certify that the waste minwrttaabon statement Identified in 40 CFR 25227(a)(V i am a large quantity generator)or(b);4I am a shall quan.ty generator)is true <br /> Gereralvrs'Olieror's Prtnle!/Typed Name Signature Month Day Year <br /> rj <br /> I :e:.s`ocan 5r:prte^15 <br /> z T a s;_r,er s ID I mport oo U 5 Li Exwrt fi ,l r S Port of entry,extl. - <br /> gna:ure fcr exports only, <br /> .7.TransporlerAtJrnowfedrprtent of R Date lea ng J.S <br /> � ece�t of Materials <br /> Traworler i Prmled'iyped Name <br /> Stgnatnue Month Day Year <br /> a <br /> rn <br /> Transporter 2 Prinled7yned Name Signature Month Oar Year <br /> rx <br /> H <br /> 18 Discrepancy <br /> 18a.Discrepancy Indicator Space Quantity 0 _ <br /> I__f Type _I Res d.e ❑Parka Refection _ =.i Ryectior. <br /> Mandest Reference Number <br /> 18b,Nzera'e Fac,7;ty ice Generator US EPA,0 Number <br /> V <br /> Faci,%'s Phore. <br /> Lo t8c 5 Sha u e ctAllerrate Faaly nor Generator <br /> Q Mar th Day Year <br /> z <br /> t9_Hazardous Waste Report Mariagemenl Method Codes a codes for hazardous waste treatment disposal,and recyd;ng systernsi <br /> LU 7— <br /> C 2 3 4 <br /> 20.Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as now in Item lea <br /> PtirltedffypedName Signature Month Day Year <br /> EPA Form 8700-22(Rev 3-05; Pretnous editions are obsolete <br /> I i`—SaF=fv 4f I.1 KACtt IT?' Fri Gf:NEi7AT0R <br />