CORRESPONDENCE_2007 - Laserfiche WebLink

Home Browse Search

lea§e print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST M'00`401'1`"I 002JI-82459 JJK 5.Generators Name and Mailin Address� GeAeM1s% ress(if different than mailing address) '. , j AVN 11,117018& 1750101"& IT�I Ov KI N I A Fityl VkJOrth 'I"N' 16W, �44 wM4,v4 i A IPOOtf' Generators Phone: R1 1-4 114)-•-1,042 6.Transporter I Cgmppny Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number (%%fiicaf A flkyflav R.z'wl IKeWwwui 4,"it y,('A 9321" Y59 iii(A- I I Facility's Phone: ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. ix N Ofs,Q I tfTV'r ,- H"i I I I, V",A-Jill Z 2. ul 3. 4. 14.Special Handling Instructions and Additional Information ' wtue PuFf"1"Pt,WIW-14 I loft-Umfi Malt'ital 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, 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. 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. +[;G5;e ors/Offerors Printedfryped Name Signature ; ,7nera,tcMonth Day Year IA7107 -1 16.International Shipments Import to U.S. El Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Pdrted/Typed Name Signature Month Day Year 0 P Zd Transporter 2 Pdntedrryped Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space 0 Quantity 0 Type 1-1 Residue D Partial Rej,,Uon EJ Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number 12. Facilitys Phone: Uj 18c.Signature of Alternate Facility(or Generator) Month Bay Year - 1-1 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0Uj 1. 1 2. 3. 4. 120.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed[Typed Name Signature Month Day Year EPA Fo4n 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY