Laserfiche WebLink
Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OL18 No. 2050-0039 <br /> UNIFORM HAZARDOUS 1 ' Gerieratar ID hkmbet 2. PageFmergenr/ Response Phone 4. lnifestTracking Number <br /> WASTE MANIFEST J V <br /> 5. Ganerator'sNaroeandtdalingAddr=,ss . , , . Generator% Site Address (1dilerentthan mailing address) <br /> Generatays pone • <br /> I . <br /> 6. Transporter 1. Company Name. _ IF U.S. EPAID Numtser • IF7. Transporter,2, Company Meme U.S. EPA ID Number <br /> 6, Dssigp�ted Fapllity Name and SIIeAddress rr� S. EPA ID Number <br /> FEE <br /> „ . <br /> I IF <br /> Facillitys Phono: wi <br /> t <br /> 9a. gb• U .S. DOT Description f,induding Proper Shipp ng Name, Hazard Class, ID Number, 1D, ContRimrs 11 . Total 12, Unit 13. Waste Ccdes <br /> HM and Paddng Group (if any)) No• Type QuantityEd <br /> WWoL <br /> W 2. i <br /> M1 <br /> t <br /> 4 FEE <br /> IF <br /> 3d T <br /> EF I <br /> - 6 <br /> 4. NoIhl <br /> _._ <br /> r <br /> r <br /> 14. Special Handling IMictions and A dlgonsi InformOon <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedarefti the contents of this wslgnmerkare illy and aauratetydascribed above by the propershopirg name, and are doss(fled, packaged, <br /> marked and labeledrplacardad, and are in all respects in proper condition for transport according to appliceb's in;ernationaland national govemmental regulations , If export shipment and I am the Primary <br /> Exporter I codify that the contents of this oDmignment conform to the ierms of the attached EPAAcknoufadgment of Consent <br /> I certiythat he waste minimization sialement iderded In 40 CFR 262.27(a) (it I am a targe quandy generator) or (b) (if I am a small quantity generator) is true. <br /> NINE <br /> GensretorslQtfe ofs Prvrtaffyped NEma Signatu'e IMonth pay Year <br /> —j 166Intemallonal shipments <br /> L._.1 Import to U.S. El Export From U.S. Port of enirylexit: <br /> Transporter signature (for exports only): Date leaving U.S: <br /> 17, TrensporWAd(nowledgnmi of Recut aWeeWs <br /> TransoorterI PrinledPyped Name Signature Month Day year <br /> O <br /> y <br /> ZTranspoder2 PrIKednyped Name Signalure Month Day Year <br /> 180 Discrepancy <br /> 16s. Discrepancy Indication Space quantity ❑ Type ❑ Residue J Partial Rejection 0 Full Resection <br /> I <br /> Manifest Reference Number. <br /> 1Ob. Ak�nateFacirty (or Ganerala) U.S. EPA IDNumber <br /> I. <br /> Ct <br /> Facility's Phone: <br /> Ujj f8c. Sfgnalure ofAltemate Facility (or Generator) Month Day Year <br /> Poda <br /> Z <br /> Aid 19. 1d WWe RetortManagement ldelhod Codes Q,e., codes for hazardous waste treatment, disposal, and recycing systems) <br /> 3. 4. <br /> 20. Designated Facility Ovrneror Operator: Cetilloation of race pt of hazardous matedals covered by the manifest except as rated In Item 18a <br /> Priaoedf1 d Name Signature Month Day Year <br /> EPA Fottn 8700-22 (Rev, 3.05) Previous editfons are obsolete. l <br /> £ ' d £ 60MV660Z Ise} d69 : Z1Nt ` 66 LZaeA <br />