Laserfiche WebLink
Please print or type.,(Form designed for use on elite(12-pitch)typewriter) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS <br /> 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST r002182432 JJK- <br /> 5.Generator's Name and Mailing Address Generators Site Address(If different than mailing address) <br /> kftdl'� C1 Awl i4 0 4b a�'t <br /> Stfaw"i i M'S 1-1 3� I"I i%70 i A? I :5.1 A)11-11 A. I li 10 <br /> V -0 wmfl& T'%' <br /> Generators Phone: 41 1')A I k <br /> 6.Transporteri--Cpmpany Name <br /> U.S.EPA ID Number <br /> 7.TranspoAdT2-C6m0any`Name U.S.EPA ID NUMDer, <br /> 8.Designated lunflical Facility Name and Site Address U.S.EPA ID Number <br /> ( wtjf"*�M'111op4-#rw10 <br /> ')Y'7Sj (Ad St"Vimo P"a;l V4 I <br /> i'A f)32 W "00 A,io'Q'N 1 <br /> Facility's Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Heard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> ihwa;d)o-'Siff eAaritv-n'S(ohil I <br /> 0 <br /> H i IIV I I�1' X)I F11 A <br /> L <br /> CS <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> wcat NIF Wlh-"fl 1ja10fih4qp Kak"Tial <br /> 1 <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 labeled/placarded,and are in all respects in proper condition for transport according to applicable international and 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 EPA Acknowledgment 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's/Offerors PrintedfTyped Name Signature Month Day Year <br /> 1,�2 qj <br /> LJLA A-1 Al <br /> -.:i-1-6-.Tn—temational Shipments <br /> 1- 1:1 Import to U.S. LJ Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> LU 17.Transpo!Acknowledgment of Receipt of Materials <br /> jR Transporter I P' tedlTyped Na Signature Month Day Year <br /> 0 <br /> Z Transporter 2 ed Name Signatbre Month Day Ye� <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space EJ Quantity El Type ❑Resldue El Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 1= 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> < <br /> Facility's Phone: <br /> LLJ 18c.Signature of Alternate Facility(or Generator) Month Day Year!R 4 <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1 2. T 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 118a <br /> Printed(Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATORS INITIAL COPY <br />