Laserfiche WebLink
U� <br /> �7 J- 113ooeaa990 5C, PPS 10/ 10J0oi? <br /> Please print or type. (Form designed for use on elite(12•pitch)typewnler) Form Approved_ OMB No.20% 039 <br /> UNIFORM HAZARDOUS IGenerator �O f Q Q 2li: `J6 <br /> age3E Response Phan d. Tracking Hummer <br /> WASTE MANIFEST r / !/ �Q + 1 CO 83 �3`� FLE <br /> 5 Generators a Honing Address C'�� �.A [ ` tots sae Aderess(d t than mailing address) <br /> OLJ <br /> It-I � 00 -sS C,h /`'Q CO. L3►5 <br /> Generators Phone t ( a 1.� , 1 ����� Sy -8651 <br /> Transporter ny � U.S /ID NumbeO <br /> � ame .EP <br /> �JUrbt�a�6� Eav � rdnme�+-Qt. �t� ) c.�S sac 1/�►/, lA7D o' <br /> 7 Transporter 2 Company Name U S.EPA ID Number <br /> 6 Design Fa aWv Nam;and Sda Address �� ,�I 114 l.(.G <br /> CVrra✓✓� 4 }� (�Oa (_S U.S.EPA ID Number <br /> D600 <br /> Facilrys Phone: <br /> ge, 9b U.S.DOT Description(indudIng Proper Shipping Name,Hazard(lass,Ii?%umber, 10.Containers 11,Total 12 Una <br /> HM and Ped(rlg GmuP(A anY)) N; Type Quantity WLPM. 13 Waste Codes <br /> c AJA �50 -7 0 v Z D ( 0 t-J A 7 7 y 11�' DIY�6 <br /> 5a t,A �a • SPy (A rd E.� r< G , CADS t�t,�►-a , Q I Cm ZU <br /> �s 81 <br /> Z 2 - <br /> W <br /> 3 <br /> 4 <br /> 14 Special Handng Instructiars and Additional Inkirmatbi • !* o o PLC-, <br /> I . CIS 169�b 1g coo 17 I tt'7� .e._ c, .�' 3►. . <br /> tlMw•"" <br /> 5, k] <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare n at pre contents of this consignment are"and amaatety des arbod above by the proper sbipping name,and are classified,padmged, ' <br /> marked and labeledi'piacarded,and are w aU respects in proper condition for transporl according to applicable in':ematlr>,isl and nattonzl goyemmerdal regulations N export sfnipment aril I am ft Primary <br /> Exporter,I certify that the contents of this consignment conform to the tams of the attached EPAAdmatNedgmem of Consent. <br /> I ce"#19 the wade mintmtr8tion Statement identified in 40 CFR 262.27(a)(A I am a large quantity generator)or(b)(A I am a small quantrly generator)is true, <br /> ererate s nt Nam Signature <br /> ear <br /> �$ 18 <br /> —J 16.International Shi nts <br /> Z ❑Import to U.S. ❑Export from U.S. Port of an laxit' <br /> Transporter signature(lor exports only): leaving U <br /> W 17 TransporterAdToMecigment of Receipt of Materials <br /> 0 TranWiler 1 PornWyPed Nam myear <br /> a Co UO S t�Sci V 1 .2y8118 <br /> 4 Transporter PmiledirTyped Name Morith Daye8f <br /> 18 Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Qaanbly ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Refen ante Number: <br /> 100,Alternate Facility(a Generator) U.S. EPAID Number <br /> J <br /> Q <br /> L- Fad 's Phone. <br /> 18 Signaturo WASemate Fatiity(or Generator) Month Day Year <br /> 4 <br /> 2 <br /> 19 Hazardous Waste Report Management Method Codes tr.e„codes for hazardous waste treatment,disposal,and recyding systems) <br /> q 11 w , r 2 3 4. <br /> 20 Designated Facility Owner or Operala Certification of receipt of hazardous materials covered by the manifest except as noted In Nam 1&a <br /> PrintestRyptParne mar <br /> ✓..er7 -�-Z-er <br /> EPAFam 8700-22(Rea 3-05) Previous editions are orb o!ete. DESIO ATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />