Laserfiche WebLink
0 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST -;erl,-,( I �1) - I <br /> 00n <br /> CIP2433 JJK- <br /> 5.Generator's Name and MailinVddress Generator's S a A ress(if different than mailing address) <br /> I <br /> ,Vlio R� <br /> VX) I. '40"- tv"!1('J'A <br /> At'N, TO AW,it, IG"il 701" N, t <br /> Generator's Phone: h 1 4 l M <br /> 6.Transpor4r 1 CompanyiName <br /> P, I --- U.S.EPA ID Number <br /> J A <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> heqrtioow <br /> v w*'kiimaq <br /> 1%"4 (411 !N-;1d 'AT( <br /> Kei&,Xmml It Av,('A t7t i <br /> Facility's Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(N any)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> 0 <br /> 1,– ,, I I,'i 111, <br /> 9i OAl with V,,wl jq);54) <br /> Z 2. <br /> LLJ <br /> LD <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> Tla)filo k aJ(IAliXfs)U a171 <br /> Wt,,w Pwix,v ITV Witt-ti Kmolhqi,�-44,iivuol <br /> 15. GENERATORISIOFFEROR'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 /> teratoestOffewes Printed/Typed Name Signature t MonthDay Year <br /> 16 1 cl� <br /> 7 <br /> 0 A— I <br /> "JU 4 <br /> 16.International Shipments <br /> F-1 import to U.S. El Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> LU 17.Transporter Acknowledgment of Receipt of Materials <br /> 1E T Printed/Typed Name,"" Signature Month Day Year <br /> C) <br /> N <br /> IL VL 1,—o-, <br /> o <br /> Z Transprter 2 Prinedirryped Name Signature <br /> < tMonth Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El Quantity 1:1 Type 0 Residue El Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Facility's Phone: <br /> LL, 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> tR i <br /> Z <br /> C- <br /> ILI) <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0) <br /> UJI I <br /> ® 2. 3. 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 /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />