Laserfiche WebLink
Form Approved.CNIS No,2050-0031- <br /> Please print or type.(Form designed for use on elite(12-Pitch)typewriter.) t Trach <br /> 2.Page 4,Of 3.Emergency Response ,c,iqNumber <br /> Generator lDNumber <br /> UNIFORM HAZARDOUS SO <br /> WASTE MANIFEST ST <br /> Generators site Address(if diff ereritthart mailing address) <br /> 5.Generator's Name and Melling Address <br /> V—, <br /> Generator's Phone'. U.S.EPA it)N umbw <br /> 6.?ransporter 1 Company Name <br /> T.Transporter 2 Company Name U.S.EPA ID Number <br /> Facility Name and Site Address I U.S.EPA ID Number <br /> 'L;~:T', w:'i <br /> Facility's Phone: <br /> ga. 9b.U.S,DOT Description(including Prom Shipping Name,Hazard Class,10 Number. 10.Containers 1f.Total 12,Unit 13,Waste Codes <br /> HM and Packing Group, any); No, Type Quantity WU'Vol, <br /> U 0 <br /> J Z <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> Y • <br /> 15. GENERATOR11OFFEROWS CERTIFICATION: I hereby declare that the contents of this constnmentare fully and accurately described above by the proper shipping name,and are classified,packaged <br /> marked and labc!ed/pl3carded,and are in all respects in proper condition for transport according to applicableintematicnaland national governmental regulations.if export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowiedgment of Consent. <br /> I certify that the waste minimization statement identified in 40 GFR 262,27(a)(if I am a large quarititty,generator)or(b)(if I am a small quantity generator)is true, <br /> Generator's/Offerces Printed[Typed Name Signature Month Day Year <br /> =-J 16.international Shipments <br /> IM Import to U.S. ❑Export from U.S. Port of entry/ext: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> L= 17.Transporter Acknowledgment of Receipt of Materials <br /> U <br /> 'E2 Transporter Pnriecirryped Name Signature Mornn Day year <br /> (L <br /> Transporter 2 Printac <br /> Signature <br /> Month Day Year <br /> 18a.Discrepancy Indication Space <br /> 17 Quantity D Type 0 Residue ❑Partial Rejection ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) Man fest Reference Number,— <br /> U.S.EPA ID Number <br /> ca <br /> LL. Facility's Phone: <br /> -i 8c.signature of Alternate Facility(or Generator) <br /> MonthDayYear <br /> v5 1,9-Hazardous Waste Report Management Method Codes(i.8,codes for hazardous waste". atment,disposal,and recycling systems) <br /> 4. <br /> 0.Designated Facai;jh�Owner or Openator;CertMfi <br /> Prinfed TYP Nam: ca receipt re !of hazardous materials covered by the manifest except as noted in item 18a <br /> signature <br /> Ment~ Jay Year <br /> :PA Form870022(Pev,3-05) Previous editions 15 due obsolete. <br />