Laserfiche WebLink
Please print or W.(Form designed for use on epte(12-pitch)typewriter.) Form <br /> Approved.OMB No_2050-0039 <br /> UNIFORM HAZARDOUS 1.Generetor I Waher 2 Page 1 of 3.Emergency Response Phone 4.Manifest Tnackin Number <br /> WASTE MANIFESTrAj 1 7 016 6�?4 316 JJ K <br /> 5.Generators Name and Maigngmdress '" Getlera s (d different than mailing address) <br /> � � t.. plMirnti�C. <br /> ' ARIZ <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> gai <br /> s U.S.EPA InNt tbar <br /> s Ptlmef- <br /> 93. 9b.U-S.DOT Desuf i ombdig Praq} %ppirg Nave.Hazard Class,D f imb% 10.Containers 11-TOW 12_Unit 13_waste codes <br /> HM and Packing(row(I a8')) No. Type Quantity W1Not. <br /> I <br /> 1. �M NCRA HWWI us 1 SobdI ContR�Dobie j CM <br /> Q0ui <br /> f <br /> 3. ) <br /> 4. <br /> 14.Special Handling Instructions and Additional <br /> ERG#f71(PrtlilY►lIlICHI 2f ..)( # - <br /> West• r'R p r-. <br /> 15. GENERATOWS/OFFEROWS CEIMF1CATl(*:I hereby declare t hal the contents of this consignment are fully and amsatdy desrnbed above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in al r6spects in proper condition for transport accord'egbappficable mlematiorraland national govemrnental regulations.If export shipment and I am the Primary <br /> Fxporler,I certify that the contents of this corLignment conform to the terms of the attached EPAAdalowledgment of Consent y <br /> I certify that the waste minim®6on statement in 40 CFR 26227(a)(d I am a large quantity generator)or(b)(d I am a small quantity generator)is true. <br /> Generatoesl0fterors Prmted/iyped Name Signature Month Day Year <br /> teyta KerdW tri <br /> .j 16.Intemational SUpments �t <br /> F ❑Import to U.S. LI Export from U.S. P er try/exto— <br /> Transporter signature(forr exports only): Date leaving U.S.' <br /> 17.TransporterAdorow$adgmant of Receipt of <br /> Transporter 1 PrinledlTyped Name Signature " th Day Year <br /> CL <br /> QTransporter 2 Printed/Typed Name J Month y Year <br /> Ix <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Spare ❑ Ouanf y, ❑ esidue f <br /> v�y Type ❑R ❑Parfial Rejection J FuM Rejedien <br /> Manifest Reference Number. <br /> 18b.Altemate Facility(or Generator) - U.S.EPA ID Number <br /> J <br /> U <br /> rai Facility's Phone: <br /> W 18c.Signature of Attemate Faci ity(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Q.e.,codes for hazardous waste treabnent disposal.and recycling systems) <br /> 20.Designated Facility Owner or Operator.Ce ' of receryt of hazardous materials covered by the manifest except as nded in Rem 18a <br /> Pdnted/Typed Name Signature Month Day Year <br /> 1,221IT <br /> EPA Form 8700-22(Rev.3-W Previous editions a obWete. DESIGNATED FACILITY TO GENERATOR <br /> s <br />