Laserfiche WebLink
Rr <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Numbers r 2 Page 1 of 3.Emerg ncy Res onse Plloce,, 4 Manifest Trackingff�ber <br /> WASTE MANIFEST .d ":aril i fats <br /> 1; G B F5.Generators Name and Mailing Address Generators Site Add[e ( tiff r@q lhap 1a ing add ss r�wCA'VM1..3.0 C`I� Y L;�l!`kL'I <br /> 4I ry-7�9 .1,. '. +') t a x'15 : �"Y1' lTr� ;TM ' + `7 <br /> Generators Phone'. 1 , `2 °• ' a >,,ii {-5 <br /> 6.Transporter i Company Name U.S.EPA ID Number <br /> 19tt.f Y .i: •, 74 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number - <br /> - <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 1. 00 CI AUS M €3'i;I'X3 3.1 <br /> Facility's Phone: ' ra, � riJS) �'.A><.•, � ��tZ �rfa4.L�1���.�(1�.A t�,? <br /> ga. 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. _ Type Quantity WLNoI. <br /> ;Ac <br /> t z! <br /> RC l:x fill 0ig W iti i,.€Cj;i. i:t <br /> rita <br /> Z Z. <br /> w <br /> C7 <br /> 3. <br /> 4. <br /> 14,Special Handling Instructions and Additional Information 4 1 ��`-�+yi / - <br /> Oil,V•y�fQ������.eh I S lj i It A}fJ.+rdr�Au Arlo1k.M ( L <br /> N RCRA) <br /> rvt'r^ix t4ttftixr•r, sxerz-. • ttirrr:•c- •t•asst .r e"e:•.<'=r .. <br /> 15. GENERATOR'SIOFFEROWS 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 codify that the waste miplmiiition statement identified in 40 CFR 262.27(a)(if l am a large quantity generator)or(b)(ifI am a small quantity generator)is tons. <br /> Generators/Offerors Printed pe Name f Signature 1 M th Day Year <br /> i. ,f <br /> -u! 16.International S�lipmeait r <br /> ❑ <br /> z 1!1 Import to U.S. ❑Export from U.S. Port of en(rylexiC <br /> Transporter signature(for exports only): - y Date leaving U.S.: - <br /> w 17.TmnspoderAcknowledgmeh of Receipt of Materials <br /> Transporter 1 Pdn(edlrypad N e f Signature ' Mon , <br /> 0Day Year <br /> a :qtr.; <br /> Q Transporter 2iPnnted{Lyped Name Signature, - Month Day War <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quanlil <br /> y El Type ❑Residue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> r 186.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: - - <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator Certification of receipt of hazardous materiels covered by the manifest except as acted in Item 182,.y <br /> JIII' Printedrfyped Name i Signature' i Months Day Year <br /> EPA Farm 8700-22(Rev.3-05) Previous editions are obsolete. ` <br />