Laserfiche WebLink
Please print or type.(Form designed for use on 'e(i 2-pitch)typewriter) Form Approved.OMB No.205D-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Nlrrnber 2.Page 1 of 3.Emergency Response Phone 4.Mani'legTracking Number <br /> WASTE MANIFEST 01667.4316 316 JJ K <br /> 5.Generators Name and MailitgAddress - s (d agent than mailing addim) . <br /> ►�Uc, . <br /> Emend" <br /> _ x <br /> 7.Transporter 2 Company Name D.S.EPAID Number <br /> 7 CA <br /> ;. <br /> SEF= <br /> U S O�iiTew i air g PrGQer Sf. og Name,fisted Class,D 1r"K 10_tionhainers 11.Total 12.Unit 13.Waste Codes <br /> l�rl p 9 C 4 ) No. Type Quantity WL/VOL <br /> W <br /> � t <br /> r r <br /> S <br /> 3. i <br /> 3 <br /> 14.Special Har&ng Inslructiors and Additional In _ <br /> 15. G CERT IOW 1 hlereby declare that the contents of fhis cx*nment are Mly and accurat*described above by the proper shipping name,and are classified,packaged, <br /> marked and llabeledfplacarded,and are in al respects in proper condition iw transport accurdi international and national govemimental reguiations.If export shipment and I am ute Primary <br /> Exporter,1 cerfrfy Slat ft&dents of this cons4wierit conform to the terms of the attached EP)kAc1Mewbdqment of Consent. <br /> I certify tlsat the waste rrnerAwbon statement Iden in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(d I am a sinal quanfity generator)is true. <br /> Generatorsl0ftemft1PrertedfTypedName Signature Month Day Year <br /> 1— 16,intef[naliorrai S} rirents 1-1 I ❑E por!from U.S. � by <br /> LJ mporttoU.S. en lexrt -- - <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> LQ: 17.Transporter Acknowledgment of Receipt of Materials <br /> a Transporter t Printed/Typed Name c ,t S gnats a M {th Day Year <br /> V L�(� ad r <br /> QTransporter 2 Pnnted/Typed Name Month ay Year <br /> f- <br /> 18.Discrepancy _ <br /> 18a.Discrepancy Indication Space Ll Quantity ❑Type ❑Residue LJ Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> H 18b.Attemate Facility(or Generator) U.S.EPA tD Number <br /> J <br /> U <br /> LL Fac+fitys Phone: <br /> W18c.Sgnahrre of Aftemate Facility(or Generator] Month Day Year <br /> a <br /> Z <br /> 55 19.Hazardous Waste Report Management Method Codes e-,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. 3. 4. <br /> ;32 <br /> 20.Designated Facaity,Owner or Operator Certification of of hazardous materi&covered by the manifest except as noted in Item 1 as <br /> PmriedrTyped Name signature Month 555 Year <br /> 1Ge, r `� - 22 ►1 <br /> EPA Form 8700-22 Nov-3-05) PievOis editions are eb�olete. DESIGNATED FACILITY TO GENERATOR <br />