Laserfiche WebLink
Please print or type. Form Approved.OMB No.205, <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.M'622831173 <br /> nifest Tracking Number <br /> WASTE MANIFEST m Q S' (q1/- ? - S Y 0 2 2 8 3117 3 JJ H <br /> N 5.Generator's Name and Mailing Address pv opq tri �G r�ld/!5?a u/2 f Generator's Site Address(if different than mailing address) <br /> N 4/elfr-ator�f�ho(ie- G� !����y��✓ L/f �'>T 1,A►l <br /> V 6.Transporter 1 Company Name U.S.EPA ID Number <br /> to <br /> LO ?ryw NG-r'4in <br /> e• <br /> 9 7.Transporter 2 Company Name U.S.EPA ID Number <br /> Q <br /> �V <br /> J <br /> m 8.Designated Facility Name and Site Address jNr U.S.EPA ID Number <br /> 57 C- <br /> FA/L}hone: WAS, 5;4e.NmeW-e C/9 19 5;��V G/'! A/ <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WLIVOL <br /> 14h� 0 1' Nv.�/ /�[2� ��l'�24�✓S �gSl�Liti/�' <br /> g z 2. <br /> a <br /> m <br /> `n4 3. <br /> m <br /> g <br /> '-,S <br /> E 4. <br /> U <br /> d <br /> Id V� <br /> 14.Special Handling Instructions and Additional Informatio Z`��• <br /> �,.i �2 C�Ni/IA-�l�Q: /2/�l►�cJ �J'�!�/����'tk L <br /> 0 ivy5�w Ado W D <br /> 15. GENERATOR'SIOFFEROR'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,padcagec <br /> m marked and labelediplacarded,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 EPAAcknowledgment of Consent. <br /> 1 certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if am a small qu ger)is true. <br /> Generatoesl0fferors P tedryped Name SignatureJ-I Month Day <br /> Y p <br /> IT, 6ViN/q Z <br /> 16.Intematicnal.5hiprinents 1 <br /> ❑Import to U.S. ❑Export froS. o -1trylexit:_ <br /> a ? Transporter signature(for exports only): le leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> h W <br /> J J O Transporter 1 Print�yped Name Signature Month Day <br /> a �C/1 Z Z <br /> 9Z Transporter 2 PrintedfT V <br /> ame Signature Month Day <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type <br /> El Residue ❑Partial Rejection ❑Full Rejectio <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number ' <br /> J <br /> V , <br /> LL Facilit/s Phone: <br /> FWL- 18c.Signature of Alternate facility(or Generator) Month Day <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2, 3. 4. , <br /> i <br />! 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature <br /> Month Day <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYS: <br /> C <br /> kiin <br /> ■ <br /> - - -ti ilrni- <br />