Laserfiche WebLink
:ase print or type.(Farm designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050.-p939 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page l'of 3.Emergency Response Phone 4.Manifest Tracking NumberB . <br /> g� <br /> WASTE MANIFEST �Y7. 9- <br /> 2.'S , ry L <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address)' <br /> s•`,.I,' :x1ti�lsr"J~-:1�.=�.fi1a;i'�ir�l'ir <br /> Generator's Phope,Tr, <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> • t�.:'�'"o,q:`t'j,'+a (•i•G`f <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> .'i.:l;}nf..iJ 'Sru��S:�: �:: ':,"0 tri::.dl`5`y.* i�`La.✓ ..'=''.`. ,. �+' - <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> �• .. .:':f+?jf. ?�::.x't :'t:i..+�y3k:i ii.ifi� ..,d'r�-.. <br /> Facility's Phonei-,`''' <br /> 9a• 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> and Packing Group(if any)) No. Type Quantity Wt./Vol. <br /> 13.Waste Codes <br /> HM _� 1. _ _,3, i, ,. �r.. .. !,°•k.St.tht l..i�:-,:1�.1 r:.i,�. .i. !^a-"'L�d-. t,.•sY�I I- ,..� <br /> z 2. <br /> LU <br /> c7 - <br /> 3. _t <br /> j <br /> 4. <br /> f <br /> 4 <br /> f <br /> i <br /> 14.Special Handling Instructions and Additional Information <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. Y_ <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 1 am the Primary <br /> Exporter,I certify that the contents of this consignment conform to.Ihe 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 smelfluanttly generator)is litter" <br /> GeneratorslOfferoesPrintedRypedName Signature {. }"' s tom '. Month Day Year <br /> a it ,r. _ e�`• s <br /> i•i, 'a 4.,� ,::•.' Ai': ::T-at.. - ""'m X t�._ >a'a-..rs.'....aw sntM,< • :rr z <br /> 16.Inte'r`national S�ipmehls' ' z <br /> ❑Import to U.S. ❑Export from U.S. ort of entrylexil: <br /> ;e»Date leaving U.S.: <br /> -- Transporter signature(for exports only): _ ••- <br /> W 17.Transporter Acknowledgment of Receipt of Materials A , <br /> v Month Day Year <br /> Transporter 1,PnptedlTyped Name , r s r ! SI Nature <br /> i <br /> 0 r a fP Jiy f ,: rmf 4w r ' x i 3 <br /> uo S nature MonthDay Year <br /> z T�ensporter 2 PriniedlTypad Name <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ElTypeElResidue ElPartialRejection ❑Full Rejection <br /> Manifest Reference Number. --- <br /> u.s.EPA ID Number <br /> 18b.Alternate Facility(or Generator) <br /> Q Month Day Year <br /> u- Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e„codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1 z. s' Notice:State of California requires <br /> generator to photocopy and mail to <br /> 20.Designated Facility Owner or Operalor.:erliflcalion of receipt of hazardous materials covered by the manifestaiurecept as noted in item 1 DV5C @��f€�i1i;af,}OA-ys <br /> Printedfryped Name <br /> �eaSy'•..11�6?1A.:�:a,i��>c y3���a�'ui!N�e;�a <br /> EPA Form 8700-22(Rev.-3.05) Previous editions are obsolete. - ----� <br />