Laserfiche WebLink
Please Tint or type. Form designed for use on elite (12-pitch) typewriter.) o , F �` Form Approved, OMB No. 2050.0039 <br /> UNIFORM HAZARDOUS 1 : Generator 10 Number 2. Page 1 of 3. Em rgency R pone Phone 4 Manifest Tracking Number ,} ,r <br /> 4 <br /> WASTE MANIFEST t0 F, f tl 0 C7 9 Y .I- 7 4 f3 �. (Rt.1J1 7Fw7t- r: : 0167743 3 JJ K <br /> 5. Generators Name and Mailing Address _ Generators Site Address (if different than mailing address) k <br /> PAUL QI1tWO 1-001) I r R 6010 'ANY <br /> 313v) ^alli'+ 7GINitoCla L , <br /> ) Pt?t kEulf 0A J;SJa � <br /> Generators Phone 3:l.L+1`z1 nf3 +$r%21ta. <br /> 6. Transporter 1 Company Name U.S EPA ID Number <br /> 1ttYNtrU21)�@i tdiE4, .ahl �ft�f1L' OktC? {) # a 1763C <br /> 7. Transporter 2 Company Name U.S. EPA ID Number . <br /> L <br /> 8. Designated Facility Name and Site Address U.S EPA ID Number <br /> -.3 +1z 3000-1 LOYLE, AVIAU11. <br /> U.4ANOIFLb Fe 94]d 41 CA1 ) 004Q3t ) 91) <br /> Facilites Phone: ),A ' -17, - v�,f 1 I I , <br /> ga 9bd U.S. DOT Descrption (including Proper Shipping Name, Hazard Class ID Number,„ 10, Containers 11 Total , 12. Unit - ' -13 Waste Codes <br /> HM and Packing Group (If any)) \ No. Type Quantify WINol <br /> .o <br /> 1 . <br /> NON-ta( I-L4 NArAP,DOOS VWVOE., !13'41 Ib (Ul7aK'1. ukrdC SHAVING ) 181 _ <br /> Z 2. _ <br /> w <br /> tl <br /> 3. <br /> 4. <br /> 14. Speclal Handling Instructions and Additional Information - E <br /> 1.IdiERtglaVfJY t ohl7A(71' 4Hf.Eb9TkvC ;f -st(lt>•-fig ! 41!5oa) lVtaPVz,.zy2 Oa. : SJL I't�"t16'il F ft DBI APIfWL1437 BRAW'. GIIAVIN(Ks <br /> t ..ttteSlf+F1 i�s43 " A1'6'IiE.tr'dYbUH F.,t he J('IAL ITRtt (ECA (JE. 4QUIPrv5E11 ( 1.1 • - C.. ti , • <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: Thereby 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 labeledlplacarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and l am the Primary <br /> Exporter, I cediry (hat the contents of this consignment conform to the terms of the attached EPAAcknowledgmen( of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if l am a large quantity generator) or (b) (if l am a small quantity generator) is true. f <br /> Generatoesl0fferors PnntedlTyped Name Sign lure (, +`, Month Day Year <br /> 16. International Shipments <br /> f- ❑ Import to U.S. ❑ Export from U.S. Pod of entrylexit: <br /> z Transporter signature (far expods only): Date leaving U.S.: - <br /> 17. Transporter Acknowledgment of Receipt of Materials <br /> �. Transporter 1 Prinleirryped Name ! Signature / - Month Day Year <br /> ifs. j <br /> z Transporter 2 Pdnted(<yped Name V 4 € Signature' 'j" ' Month Day Year <br /> I-- <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: . '- <br /> 18b. Alternate Facitity (or Generator) F - U.S. EPA ID Number <br /> Z3 <br /> U <br /> LL Facilitys Phone: <br /> w 18c. Signature of Alternate Facility (or Generator) - Month - Day Year <br /> a <br /> z ` <br /> 19. Hazardous Waste Report Management Melhod Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)4Va - [ <br /> 3. 4. <br /> leg <br /> 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pont drryp d Name / Signature / Month Day Year <br /> 7 ! / , <br /> /i . <br /> ! -� . , �Fi <br /> EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete, _ . TRANSPORTER'S COPY <br />