Laserfiche WebLink
Published by J.J.KELLER&ASSOCIATES,INC.,Neenah,W I•USA•(800)327-6868•www.j;keTier.com•Printed in the United Stales 167-BLS-C 6 1049 <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.Page 1 of 3.Emergency Response Phone 4.Manifest Trackin Number <br /> WASTE MANIFEST .4 a h7 1 1-go o ss� qo 0 011�l 1141 JJ K <br /> 5,Generators Name and MaT g Address Generator's Site Address(d different than mailing address) <br /> B 1P-w e3 a ,.T L f e- �.�C_ <br /> �yoo •-Gc�c�s'�Lo� �. b 1 v �`a�`�- 6G �yL�o -7 <br /> Generato?s Phone: CA -! O <br /> 6.Transporter i Company Name U.S.EPA ID Number <br /> A'11\Cn XA M a r 1� C ob <br /> 7.Transporter 2 Company Name U.S.EPA ID Numter <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Dev,^ e-v., 14,P-1-0(00 v� <br /> a'o N C,-\o,ha�e0o.5+ <br /> Faal,, sPhone: IO ) <br /> 92. 9b.U.S.DOT Description(inducing Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity WtJVol. 13.Waste Codes <br /> Nos E' roL��w `ON�Gvti+4+nA�eA �vk��l OC7 i C- <br /> W <br /> Z 2. <br /> W <br /> I� <br /> l_ 3. <br /> 4. <br /> 14.Special Handhno Instructions and Additional Information <br /> 96l Nolc, i QeIr-Le-�,, -Iy�rDCc,�}�ay. W l h S�s.Qe�cded S'ol .•c.�s <br /> i (a: ,4,1c 3 hvlCo" Pow �G S <br /> 15. GEN ERATOR'SlOFFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlp!acerded,and are in all respects In proper condition for transport according to applicable fnlemational and national governmental regulations.I;export shipment and I am the Primary <br /> Exporter,1 certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generato,'sl0fferces Printed/Typed vName Signature Month Day Year <br /> ' I-S g <br /> --r 16.International Shipments <br /> El import to U.S. ---_ ❑Excorlfwm.U.S_ Port etrylexit: <br /> Z <br /> Transporter signature(for exports only): <br /> ' — <br /> W 17.Transporter Acknowledgment of Receipt of Materials I <br /> 7r nspo ter 1 Pr nted ed Na ne Irl By Year <br /> A 1Pro <br /> Vl,6+ <br /> -z nsporter 2 Printe yped Name ay Year <br /> 18.Discrepancy `/� l �� / d/�V�Y�C� <br /> 18a.Discrepancy Indicaton Space ✓� s <br /> ❑ QuanGly Rejec6cn <br /> I <br /> Alternate Facility(or Generator) <br /> FadliVs Phone: <br /> Q18c.Signature of Alternate Facility(or Generalor) Day Year <br /> rA 19.Hazardous Waste Report Management Method Codes <br /> LU <br />