Laserfiche WebLink
Form Approved . OMB No. 2050-003 <br /> Please print or type. 2. Page 1 of 3. Emergency Response Phone <br /> 4. Manifest Tracking Number <br /> UNIFORM HAZARDOUS <br /> 1 Generator ID Number - <br /> 17 <br /> WASTE MANIFEST1. , ,, , , �, . ° :t'r Generators Site Address (if different than mailing address) <br /> 5. Generators Name and Mailing Address <br /> g :I SsL <br /> l r 3t st II � � ' "' U .S. EPA 10 Number <br /> Generators Phone- <br /> 6, Transporter 1 Company ame <br /> U .S. EPA ID Number <br /> Ilk Il 7 Fs <br /> 7 . }Transporter 2 Company Name - <br /> 4 s � � I +� •_ <br /> If f^) ,° r ' U.S. EPA ID Number <br /> 8. esignated Fac+ldy Name and Site Address i i s § b € i . F <br /> �jlllt <br /> Ric mfiII ; <br /> Facility's Phone I ` - . t 10. Containers 11 , Total 12, Unit 13, Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> 9a 9b, U.S DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br /> HM and Packing Group (if any)) # III,4 y <br /> 110 Will <br /> , ITw '� 4c1s ur {�, . - , to , <br /> 0e' <br /> Z 2. <br /> W <br /> C7 <br /> 3 <br /> UU <br /> 4. <br /> ENVIRONMENTAL HEALTH <br /> 11 <br /> ctions and Additional Information <br /> 14 , Special Handling Instru <br /> Or � c t <br /> e + F11t .e r i ¢ ? � {ss rr�311rat � � itr .f <br /> + [ s r f .�' i t 9 l <br /> i Y # tt ,�- 9 k§ 34 Fl .. '<" d t f %6f <br /> clcondition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br /> i <br /> 15. GENERATOR`SIOFFEROR'SCERTIFICATION I hererbydeclare that the contents of this consignment are fully and accurately described above governmental <br /> the proper shipping name, and are classified, pec age , <br /> marked and labetedlplacarded, and are in all respects proper <br /> Exporter, I certify That the contents of this consignment conform to the terms of the attached EPAAcknowiedgmenrof Consent, Month Day <br /> 1 xportethat the waste he contents statement identified c 40 CFR 262.27(a) (if I am a large quantity S gnatueratore or (b) (if I am a small quantity generator) is We. <br /> . � <br /> Generator's/Offerors Printedlryped Name @ .- <br /> fa <br /> .vim . ��a _ <br /> f - <br /> d 7 Port of entry/exit: <br /> 16. Inter kona Shipments Date leaving U.S.: <br /> Export from U.S. <br /> WMMMI <br /> ❑ Import to U.S. <br /> Z Transporter signature (foUPIr exports only): IN <br /> Month Day <br /> w 17. TransporterAcknov+ledgmentofReceipt ofMaterials Signature <br /> LLJ <br /> F— Transporter 1 PrintedlTyped Nam <br /> � " 1 .•� _� <br /> O , . <br /> } <br /> y ,. } _ . Signature <br /> Z Transporter P " to TTyped Name <br /> ed <br /> 18. Discrepancy ❑ Residue ' Partial Rejection <br /> El Full Rejectic <br /> 18a. Discrepancy Indication Space E` Quantity ❑ Type <br /> Manifest Reference Number: I: Will <br /> WIN am U.S. EPA ID Number <br /> i111 11 WIN WIN <br /> 18b. Alternate Facility (or Generator) <br /> J <br /> �j Month Day <br /> LL Facility's Phone: <br /> Altemate Facility (or Generator) <br /> W 18c. Signature of <br /> QIII I III Will <br /> I II 4. <br /> 19. Hazardous Waste Report Management Codes (i.e., codes for hazardous waste treatment,disp3sel , and recycling systems <br /> 4 2. <br /> d 1 ' <br /> exce <br /> 1 .fff <br /> Facility Ovin or Operator: Certification of receipt of hazardous materials covered by the mS gnaWrp Pt as nded m Item 18a r ; <br /> anifestM <br /> 200signatedonth Day <br /> Pnnted/TypedName <br /> { !r E I NATED FACILITY To GENEI <br /> t . _ _ _ .. . . � � . n w� ❑.... ,,ni� oAitinns era. obSOlete . <br />