Laserfiche WebLink
Please nrintfhr tvne. (Form designed for use on elite (12 -pitch) tvoewnter.) <br />6121372914M Sri PPW 11/18/me Form Approved, OMB No. 2050-003q <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. a DESIGNATED FACILITY TO GENERATOR STATE (IF REQUIRED) <br />peen l gon rma um sppmpos po i ter m l 0502.211 gum" the p"rod• is <br />-UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number <br />CAL000280399 <br />2. Page 1 of <br />1 <br />3. Emergency Response Phone <br />(somgaaas <br />4. Manifest Tracking Number <br />002200563 FLE <br />5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) <br />Sum <br />280 An <br />SRSAME <br />Mentaa CA 95886 <br />Generator's Phone: 209)9 92 . <br />6. Transporter 1 Company Name U.S EPA ID Number <br />"pforbors EnAront-im al . Ino MAD 0 3 9 3 2 2 2 5.0 <br />7. ran iter mpany Nae S. bei <br />nated Facirily Na5e and Site Addresg V U.S. EVA116rNurWr- <br />Own Harbors AraPill LLC U T D 9 8.15 5 217 7 <br />11600 Nortfi ADW Rand <br />GM t VIII , UT 84029 <br />Facility's Phone: 43F• 984$1 <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WtNol. <br />1NA3077, HAZARDOUS WASn. $OUD, N.O.S., (LEAD?, <br />141 <br />D00$ <br />o9, <br />PG <br />001 <br />DF <br />00040 <br />P <br />Z <br />2. <br />w <br />t9 <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information SO! 7291 FLEETi5284 <br />1.TARGET-GRIM ERGi171 1X15 <br />15. GENERATOR'SrOFFEROR'S CERTIFICATION: I hereby 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 labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I cerlity that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I w411 quanboflerat5iL6true. <br />Generatoes/0,9mes nntedfTyped Name Month Oay---7e-a-r <br />�4 11 21 108 <br />ct rt v N <br />16. International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />Z <br />Transporter signature for exports only): Date leaving U.S.: <br />LW <br />Li <br />17. Transporter Acknowledgment of Receipt of Materials <br />Li <br />Transporter 1 PrintedrTyped Name Signature <br />on ay Year <br />a <br />MRCASAlItT1AGOJD <br />u1 11121 108 <br />zlk-6MeV <br />2 Printe Name Sign I Mo7yay ear <br />tied <br />off <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />Q <br />U <br />a <br />LL <br />Facili 's Phone: <br />Lu <br />18c. Signature of Alternate Facility (or Generator) Month Day Year ' <br />a <br />Z <br />(7 <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />C1 <br />2, <br />3. <br />4. <br />20. Designated <br />Facility Owner or Operator. Certification o1 receipt of hazardous materials covered by the manifest except as noted in Item 18a ! ` <br />Phntedrryped Name 5 nature - <br />-i r <br />1Oa y Y <br />b] <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. a DESIGNATED FACILITY TO GENERATOR STATE (IF REQUIRED) <br />peen l gon rma um sppmpos po i ter m l 0502.211 gum" the p"rod• is <br />