Laserfiche WebLink
Please prim or type. <br />UNIFORM HAZARDOUS 11 Generator ID Number <br />WASTE MANIFEST <br />0l <br />5. Generators Name and Mailing Address <br />1.. t' t .i �'i- r7 � rV £- s- � .i 'It '} 'c, •. <br />5 t'fGGEM 1 T E AVE <br />8. Designated Facility Name and Site Address - <br />1 st ,ent ur 'y EMN., LL -C <br />Iii=kgI.ari, Ea_ <br />�ernlayl NV S34138 <br />Facili 's Phone 7 ? cevn F; , -,, <br />9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />HM and Packing Group (if any)) <br />1UN1791 Waste HvDochiorite Colutisns 8. PG <br />1.1.1> ER[-�#I9-+ <br />Form Approved. OMB No. 2050-0039 <br />3. Emergency Response Phone 4. Manffnt Tracking Number <br />�--. 013120476 FLE <br />L A <br />Generato s ddress (if different than mailing address) <br />I^ 'y i 5 E Y =._i :'E:Ti TE <br />i-'\ l' <br />U.S. EPA <br />10. Containers 11. Total 12. Unit <br />13. Waste Codes <br />No. Type Quantity WUVOI. <br />�r0�0 c vjro._. <br />15 GENERATOR'SfOFFERQR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are dassified, 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 EPAAcknowledgment of Consent. <br />^ I prtify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (ffi am a small quantity generator) is true. <br />J I 1 rn vinfaaer1ai nnlpments <br />Impart to U.S. ❑ Export from U{S. <br />Port ofe t /exit - <br />T Porter sgnalmm Ifor exports only)' ^ <br />D�iNing U.S.: <br />GC 17. Transporter Acknowledgment of Receipt of Materials <br />w <br />Transporter 1 Printed Typed Name k �e <br />Month Day 1 <br />ZR Anthony Mat -k � <br />♦ a;; � �. <br />Transporter 2 Printed/Typed Name 51g re <br />7b� f I <br />_J <br />�{j <br />. <br />M — <br />Month ay <br />C, <br />18. Discrepancy <br />18a, Discrepancy Indication Space <br />1:1 Quantity ❑ T YPe <br />❑ Residue <br />❑ Partial Rejection <br />❑ Full Rejection <br />18b Alternate Facility (or Ge <br />Manifest Reference Number:nerator) <br />U.S. EPA ID Number <br />V <br />Facings Phone: <br />W 18c. Signature of Alternate Facility (or Generator) <br />Month Day <br />Z <br />Z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />I I I <br />LU <br />1 12- 3. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />1�rin pea N ' na <br />C <br />-MonthtL lla&��A__ <br />n i <br />OF <br />vyn2e <br />air <br />51 jl <br />I I <br />1 <br />EPA Form 8700-22 (Rev. 17 Previous edl'ansare obsolete. <br />R_�PGNATED FACILITY TO EPA s- <br />NIFEST SYS' <br />9700-2c___12v3 _.AL2 -1O072032 941053328 041379818 <br />M <br />DD12142219 S.D+17422 19 <br />