Laserfiche WebLink
Please print or type.(Feng designed for use on ekte(12-pitch)typewriter) Form Approved.OMB No.205D-0039 <br /> UNIFORM HAZARDOUS t Generator ID Number 2 °age'of 3 Emergency Response Phone 4.Rlan'rfest Trra]ckii Num w ,! <br /> WASTE MANIFEST _► , �� _ F;;: ���r� [ F L E <br /> 5.Generators Name and Mailing Address — Generators Site Address(K'differentlhan mailing address) <br /> orit�Thames St C�strtl�t (Si�M l` <br /> Transporter6. 1ompany Name ' U.S.EPA ID Number <br /> ,f <br /> N—c���g <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA 10 Number <br /> LAB Ecalca <br /> i, <br /> PO Borth# i IMAW S Beady �T���(X= <br /> Fa s P ohe: <br /> Be. 9b,U.S.DOT Description(imduding Proper Shipping Name.Hazard Class,iD Numoer, 10.Containers 11.Total 12.Unit l3.h'asle Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.lvd. <br /> 1. <br /> v lv.A i18 t#ra t�Es rcr wa3lL,k�,�tsi .n.c,_�.. 'Ilta�c} ► ` #-4 .1 {1E14 <br /> 'Sokoom,9.PCAt <br /> w <br /> w 2 , <br /> LD <br /> i <br /> z <br /> I <br /> c <br /> 'r <br /> i <br /> i <br /> 14,Special Handling Instructions and Additional information <br /> �,r l 1�trC ,f 14iSb f3 €kNarmt X D1400112 <br /> 1I)FRGl l h i 4Ar-377%27"r <br /> A, <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 labeledlplecarded,and are in all respects in proper condition for transport accosting to applicable intemational and national governmentalulations.H <br /> reg export shipment and I am the Primary <br /> Exporter,I certify that the contents o`this consignment conform to the terms of the attached EPAAclmowiedgmertt 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)(d I am a small quantity generator)is true. <br /> Gerera&s/Offeroft PnntedfTyped Name Signature ay ear <br /> j 16.international Shipments ❑ I <br /> Z Import to U.S. ❑Export from U.S. Part of entrylexit: <br /> — <br /> Transporter Signature for exports on : Date leaving U.S.: <br /> L ' <br /> w ,7.Transporter Acknowledgment of Receipt of Materials <br /> o Trahnsporta l Printe.dlfyped Name_ 44 Signature an ay Year <br /> a Transporter 2 PrintedlTyped Name 5ignallureMonth uayl ear <br /> Q <br /> 18.Discrepancy <br /> 18a.Discrepancy lndication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Ahemate facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> a <br /> -acif s Phone: <br /> 18c.Signature of Alternate Facility{or Generator) Month Day Year <br /> 4 <br /> z <br /> 0 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 11, 2. r <br /> 4. <br /> 20 Designated Facility Owner or Operator-Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pnir lTyped Name Signature Month Day Yea <br /> E'PA Form 8700-22(Rev.3-05) Previous editions are obsolete GENERATOR'S WITIAL COPY <br />