Laserfiche WebLink
�9 t(nkor tp e,(Form doigned for use on olite 12 Itch)typewriter.) Form Ap roved.OMB No.2050.0039 <br /> UNItE�M MAxi4RA0US ,1 Gaiterator ID Number. 2.Page 1 of 3.EmorgerlcyKesponso Phona 4 ManiPost.Ttaakfnq Numbor <br /> WA57 Ml�Nll" �1 ti, 1 'fr3r78 9 JJ <br /> 5 Ganeiatoes Name.and Malifng Address, Generatdi's Site Address(if differen(than'malling address) <br /> AnMM A',, TION Sr!90, <br /> WE E 4 S. 3,2BER40 t ST <br /> MGM <br /> 00herator's Pboneg ' -r <br /> Transporter 1 Company Name,...,, U.S.EPA ID Number <br /> 7.TransPorter2 Company Nam q U.S.EPA ID Number, <br /> 8 Designated Facliily.Name and Site Address U S EPA ID Number <br /> lute MTH H"n-R <br /> YES` C eNT <br /> Facltity's.Phona. )?' "�' ' <br /> grj 96 if S DO f DeSaipifo�t(�rtciudfng Proper Shipping Nama;%,H <br /> 113.IDNumb10.Containers ::11,1bial 12 Unit 13.Waste Codes <br /> MM and Packfng;Group(f any)) No, 7ypg tauanilty WI Nol; <br /> .f t W '€ MUDdl. 1 p4 a <br /> lo <br /> 3 ( ' <br /> 4. <br /> ` 14$pacfal Mandi iig Instruotions An Adddfonal Information � <br /> �++?y�pp�pM�'.�N9Agg(��U�QFq USF,��APPRM19a PPZ <br /> t�'£ ktTSi#Eka1 tmiA'r:VlSuf+ A`Sii°l#r,:a.,'"8f1:- vT .. . <br /> 15 GF.TtEffATOfi$1QFF>»RQR'S C I�TIF(CAi70H t hereby,declare that Ure r ptentsot this consignment gra tuilyend acouratelK dascrl5eaabove by lite proparshippinpttgme;and oto ctass(ffod,pactrAgad, <br /> mfirltad andfa6 ladtplacar ed ansta Flraltras}iectstrt ropeFcorxfrbar 7a jiart§po�ta+ rdln'Old applleabte infe rnatfonal fid nationaltjovammantal.;[e ulmans.if axpbrf siffpment and l';aro ifle Pifmd <br /> Exporter Fcetttfy thatlflecknienfa ofth cortsfgnm®nteontorm to ih$tarrds of the attac)ied EPAAcknowledgmen of Goitsenj. <br /> tceridy tbat;tha waste n>rn�r)iizat(on statement lda*titled in 4aCv 262,27(a)Zlf l am a.ianj, quaOiily generator).or(b)((fTam p to)aitguan4ty generafoi�lslma: <br /> Ganeialrir s(Offeto s Pdnled(Iypad Name Signntuto t Mpnth Day Yeat <br /> .»t 6 nternallon Sh�pmenls <br /> �(mortt6US _, 1 �Cxportfrom Lo = f'ottotenfrytexff_ <br /> Transpprfer sfgnq(Via(fatexoprls,aniy Date loav(ng if ;. <br /> 17 Transpottet:6 p ladgro of Receipt of Mafedals <br /> Transporter i PrfntedfTyhed Na a Sfgpahue Month Day Year <br /> y ' <br /> Transporter 2 nStted_ypod Name Signature ° M4n(h y Year <br /> ': t&Discrepancy <br /> 10a:Discrepancy indication Space quantity ❑Type Residue ff J } <br /> L....I Partlaf Rejection Full Rejection <br /> Manffost Reference Number. <br /> 18b.Alternate Facility(or Generator) U,S.EPA ID Number <br /> u�. p'aclf(ty's Phone:. <br /> 18c,Signalure of Alternate Facility(or Generator) Month Day ear <br /> 19,Hazardous Waste Report Management Method Codes(I,e„codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU <br /> ���`- ��1•, tri <br /> 20,Designated Fadlity Owner or Operator.Ceriipcaten of recelpl of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrntedfTyped Name Sgnaturo Month bay Year <br /> �..rQ•r' ef�; � f...,; J` <br /> n�a r_.....n-.nn nn,n.S.n ns•. e,...r............:_ _,...,.r. � . <br />