Laserfiche WebLink
T;)3 J <br /> 1L I <br /> Form Approved.OMB No.2050-0039 <br /> prease print or type.(Form designed for use on elite(12-pitch)type'Nriter.) 4 ::i ing Number <br /> - Paget of 3,ET ;y poptlff-jhm <br /> 1.Gener—ator 10 Number 6-1-, .o'- <br /> UNIFORM HAZARDOUS U, 6 SKS <br /> WASTE MANIFESTSKS <br /> 5,Generator's Name and Mailing Address <br /> t n <br /> Generators Phone, Number <br /> 6.Tra <br /> U.S,CM <br /> 7,Transporter 2 Company Name <br /> L <br /> U.S.EPA ID Number <br /> 8 Designated Facility Name and Site Address 'S <br /> Facility's Phone: 10.Containers 111.Total 12.Unit <br /> ga. gb.U.S.DOT Description(.Including Proper Shipping Name,Hazard Class,ID Number, No. Type Quantity wt./Vlo. 13.Waste,Codes <br /> HIM and Pecking Group(if any)) <br /> SO' <br /> 0 <br /> LU <br /> Z 2. <br /> Lu <br /> 3. <br /> 4, <br /> 2 <br /> 4 <br /> 14.Special Handling Instructions and Additional Information <br /> L) <br /> Q <br /> 5. <br /> GENERATOW&OFFEROR'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 accordin, 4o applicable international and national governmental regulations.if export shipment and I am the Primary <br /> Exporter,I carlity that the contents of this consignment conform to the terms of the attached E Hoknowledgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generator'slCiffe or's Prin yped Name Signature month Day Year <br /> ' <br /> -j 16.International Shipments <br /> iL- ❑Import to U.S. Export from U.S. Port of entry/exit: <br /> Transporter signature,(for exports only): Date leaving U.S.: <br /> 17.Transporter Adowledgmerit of Receipt of Materials <br /> UJI er 1 Prin Signatury- <br /> I.- Name Imonth Day Year <br /> cc Trap" " I -I ' I / , <br /> co Month Day Year <br /> Tran nted[Typed Name Signature <br /> • -Ak'2-TZ-rF7 <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication SpaceQuantity E-j Type ElResidue Partial Rejection ❑FO Rejection <br /> Manifest Reference Number: <br /> U.S.EPA to Number <br /> Facility's Phone: <br /> w1 8c.Signature of Alternate Facility(or Generator) tsonth Day Year <br /> U5CD <br /> 19.Hazardous Waste Report Management Method Godes(i.e.,codes for hazardous waste treatment disposal,and recycling systems) <br /> Uj <br /> J. 2. 4. <br /> 4-Y <br /> 20-Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in item 118a <br /> PrTAed Pd Name Signature Month Day Year <br /> EPA rqrq <br /> �Q 2gjRk4 A70) Previous editions are obsolete. <br /> DESWATED FACILITY TOr GENERA Of <br /> A i, <br />