|
Oct. 15. 2015 4: 34P - Brannon Tire
<br /> r1, No, 1465 P. 4 •
<br /> i
<br /> Please print or type. Forth desl nad for use on lie 11 pitch)IypeyMter,) Form roved.OMB No.2050.0039
<br /> UHIFORm HAzARnouS 1,Generalor ID N mbar 2.Pag=I-Emgency Response Phone 14.Mantras(Tracking Number i
<br /> WASTE MANIFEST 2 '`> JJ K
<br /> S.Generator's Name and Malling res Oeneralo a iia dress n rfiereril then mailing dress)
<br /> ).1PA1,11,1014 TIR11
<br /> ro Go 'il71)ri CO!i t;I.Ml"pm"sill I mr-Ni,11-
<br /> 06899 (."A $K20111 ,4;i(�f:f<I ON (:'A :)?lJ'tQ
<br /> 6,Transporter 1 Company N me t , U.S.EPA lb Number
<br /> Transporter 2CompanyName U.S.EPA ID mer
<br /> B, b i ams and il'a' dress" U, ,'E RfD flet �'r ' -r � °• '
<br /> Z1,I)1': ii"I '1.1,`:°'i'
<br /> Faali
<br /> YLs RA Ae` 8Z,;Vt-V.if)i
<br /> one:
<br /> ga, 9b.U.S.DOT Descdplbrt(hduding Propelhipping Name,Hazard Class,ID Number, 10.Conlainers 11.Total 12•unit
<br /> M and Packing Group(if any)) 13,Waste Codes
<br /> No, Type Quantity WtNo1,
<br /> 1.
<br /> o l�{iId'Nc;I3A 1(AM4'10t),:,WA;.`,1 I' I1.081{['.R 11•V ,;I(AVINGi.,)
<br /> 1/? —
<br /> t
<br /> 3. r '�,es 16
<br /> 20 5
<br /> 4.
<br /> ENMU IV
<br /> 14,Special Handling Insiructlons and Additional Info aiton
<br /> f)rMe.1iNlvirU-fVV. (..Ud'1?'1 -2 r,)/c
<br /> 1S. DENERATOR'SIOPFEROR'S CERTIFICATIo):I hereby declare chat the contents of this conslgnment are fully and accntaly dewrlbed above by the proper shIpping name,and are dassllled,packaged,
<br /> marked and labeled/placarded,and are In all re peck in propercondiuon nor transport according to applicable international and WOW governmental regulaO ns.If export ehlpmentand I am the Primary
<br /> Exporter,I certify that the contentsof Ihls const men[conform to the leans or the attachsd EPAAckrwwledgmenlotConsenl.
<br /> I certify that the waste rain nkalk n Etatamentli entitled In 40 CFR 262,27(a)of I am a large quantify generator)or(D)(ill am a small quantitygenshbij is true.
<br /> GeneratorslOfferpo(sf6nladrlypedNaa�Jme, 5ignalure Month Day /Year
<br /> X
<br /> J 16.International Shipments
<br /> F ❑Import to S. ❑Export nom U.S. Purl of enlryle)dl,
<br /> z Transporter eignelure(for exports only); Dale leaving U.S.:
<br /> rY 17,TransportarActmowtedgmenlofReceipt ofMawla
<br /> Transporter i Prinledtiyped Name 9ignalure Month Day 7ear
<br /> O , ,
<br /> Trane rter 2 PdntedlTyped Name Sgnalure Month Day Year
<br /> a
<br /> 1„8.'Disp'epancy
<br /> 18a.Discrepancy indication Space ❑Quani ❑Type ❑Residuei
<br /> ElPaNaI Re)eclion , ❑Full Rejection
<br /> Marifeal Reference Number,
<br /> 18b.Alternate Faclllty(or Generator) UA EPA ID Number 'rt
<br /> � 1
<br /> U
<br /> FacTly a Phone;
<br /> W 19c.%nature ofAllemale Faoility(or Generator) 7771—Y ,
<br /> Year
<br /> 4
<br /> 19.Hazardous WBsle Report Management Method as(i.e.,codes for hazardous waste treatmen6 disposal,and recycling systems)
<br /> 1.
<br /> 121 3. 4,
<br /> 20.Designated FaC@ty Owner or Operator.Cadilt0a' of recefpl of hazardous rnatedala covered bytha mantreal except ae ncW In Item Ilia �_t
<br /> rinledrryped Name Signature Month Day Year
<br /> r'
<br /> EPAForm 8700-22(Rev.3*) Previous edl(lons ar obsolete, GENERATOR'S INITIAL COPY
<br />
|