Laserfiche WebLink
3 r w+u--cc�•cv.o i,r+t_+cw�u ywnc� �Y i r�t n�rc r u�r t,31 a i 1{S ITI f=UrOciO+t i'y SUtOC�41'y <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 Number 2.Pa7775-7 <br /> Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST ARJO00278325 11c6G9 011386081 FLE <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> -c r Vii.. iy�r _ -v <br /> 2002531cr64 tZ-10 I 31sSs MR 1i+1 LiR.tc1-_01 <br /> Generator's Phone: R U_-ON. C A 31J .10 r R 1 - N. "i t <br /> ti.Transporter 1 Company Name U.S.EPA ID Number <br /> jy. t i= 1{'IJ f!,le. <br /> 7.Transp3lillj=aTany Name U.S. PA ID Number <br /> rWOL � <br /> 8.Designated Facility Name and Site Address s' .y t '-,L n r sXr V LiIIN. LLA' U.S.EPA ID Number <br /> Fit fitLu'1. NV 3'31-1106 <br /> Facilii es Phone: f <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit No. Type Quantity Wt.Nol. <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> ;; 'UN1131. Waste tivoriC11 ar ite 1a11Atic-n;_z B. PG 1 F.F ZOO 15 P 122 <br /> 0 III. ERG#15t- <br /> W X 2UN195O. Wakste Aerasois. f aiemable . .1. ERG#126 vF 00037 t=` 331' 001 <br /> c� <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 0c 51 !'201 e�� t, I�10 Ci,i-0) 2' 10541 S <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, <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 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 small quantity generator)is true, <br /> am r� l uremonth ay r <br /> 16.international Shipments ) <br /> Z 0 import tor U.S. ElExport from/U.S. Port ntr7v�xit: <br /> Transporter signature(for exports only): Date bDavipfp U.S,: <br /> W 17.TransporterAdmowiedgment of Receipt of Materials ^, <br /> '­ Transporter 1 PrintedlTyped Name nature / UN/ <br /> //// Monthay Year <br /> a Antttanv Mack �� �.JV( 1412 105 rZ13 <br /> ransporter 2 PriName Signature `` Month ay Year <br /> Iv(i e� <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> 0 <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 <br /> hazardous waste treatment,disposal,and recycling systems) <br /> Lu 1 <br /> �l I2. <br /> -�AtA 13. <br /> 14. <br /> AAA <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed Name I SgnaWre Month Day Year <br /> EPA Form 8700.22(Rev 3-05) Previous editions are obsole . DESIGNATED FACILITY TO DESTINATION STA"'E(IF REQUIRED) <br /> 5700-22_12v3 CAL.200- kZ13c 54105 371 104131611,� M P%O20519 SD02,01519 <br />