Laserfiche WebLink
Please print or type_ <br /> UNIFORM <br /> WAST HAZARDOUS 1 Generator ID Number Form Approved,OMl3 No.2050.0039 <br /> E MANIFEST 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> 5.Generator's Name and MafiingAddress WAS <br /> Gen?jejQts Si ggddress fif�Iffgr g than miaddress) <br /> Generator's Phone.Phone. 31 VU NkiLEEc. RD <br /> 7 RA(.Iy CA l <br /> 6.Transporter 1 Company Name 1tir l: i E•�i¢+? <br /> 7 7ransporter2 Company Name U.S.EPAID Number <br /> U.S.EPA fp Number <br /> 8.Designated Facility Name and Site Address <br /> r.. .�4U c, i.,tr 1If(1L bE.Fi'Jit;E.:-, JS.EPA ID Number <br /> CI)t71_T<7�;E;, qZ 851��3•-92t7,� <br /> Facility's Phone:. (52o} , <br /> 9a. 9b.U-S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number,HM and Packing Group(if any)) 10.Containers 11,Total 12,Unit <br /> 1. No, Type Quantity WtNol. 13.Waste Codes <br /> o RQ UN1950 WAS-r AERDSOLg <br /> t tr <br /> w 'DINT , BR'SCA175i, (Crr)i}i <br /> M 2. <br /> LU <br /> ffr m-1993 ."ASTE FLAMMF�RL <br /> E E_zC�t}z�rS N. <br /> {f, IIFI�, hl;NEPR- SPIRITS), (k)o'i), <br /> 3. <br /> RO LN199w�sT FI..r,Mrrcl r E 11[f) IDS, N.0 <br /> , , .. <br /> 4. <br /> IZi <br /> 14.Special Handling Instructions and Additional Information <br /> .J r,44 Lnh 4.wL,: ;,tic, <br /> 15. G€NERATOR'SIOFFEROR'S CERTIFICATION:I hereby dedare that dre contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled)p€acarded,and are in all respects in proper condition for transport according to applicable intemationaland 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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization state nt iden ed ip 40 .. <br /> (if I am a large quantity generator)or(b)(ill am a small u enerator)is true. <br /> GoneratoeslOfferofsPrintedi7ypedName -^' - a+/ SignatY..� <br /> ure fifi Month Day Year <br /> `A <br /> 16-International Shipments <br /> ❑ImportmU.S. ❑Export from U.S. Portofentrylexit <br /> Transporter signature(for exports only); Date leaving U.S.: ~ <br /> rY 17 TransporterAdorowledgment of Receipt of Materials <br /> tw- Transporter 1 Pnr'bRdClypeGName Signature .�.y Month Day Year <br /> o.. <br /> U) Transporter 2 Printed/Typed Name Signature Month Day Year <br /> r <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> AIIamateFauty <br /> a (orGenerator) U.S.EPA ID Numxr <br /> J <br /> U <br /> rai Facility`s Pharre: Month Day Year <br /> 0 11 Signaarre WNW—Fadfrty(or GeneraW) <br /> a <br /> Z <br /> 19-Hazardous Waste Report Management Method Codas(i.e.,codes for hazardous waste vea hent,disposal,and recycling systems 4 r <br /> 3. <br /> O <br /> 20.Designaled Facility Owner or Operefor Certification of receipt of hazardous <br /> materials covered by the 5 gnafureerriest cept as nded in Item 180 Month Day Year <br /> PrinledlTyped Name <br /> _... ... aa_alp nbsolete. GENERATOR'S INITIAL COPY <br />