Laserfiche WebLink
Please print or type. Form Approved. OMB No. 2050.0039 <br />UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. M nlie)st TrackingyNumber «�� �1+ <br />I oil; 4ollid! ri) j f(:! :i!' I .)Il t;' +J �' � R. JJK <br />WASTE MANIFEST <br />5. Generators Name and Mailing Address, C' 1 Generator's Site Address (if different than mailing address) <br />1',j',Qt/l1+'•ILIi iliac. ItIR bLF;'rry t��,ii-f:: <br />i a zo u''? til lArk l W WAY <br />ty l;q, <br />Generators Phones' <br />6. Transponer 1 Company Name r r : , r U.S. EPA ID Number VAIRM 272W- ) <br />7. Transpoder 2 Company Name " "• " ^ ""'""'""' _ <br />`,:..r . ttt ; i hril?r. ltt. V' t.1tY ; ?i l l_t.9ti 11 It: t..yPOU01 /5,1122 <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />v1IMA 4L'b J WXg IL IKAPJ8hI-.R FA`( -11111 /WT(}i}1aa71idr3 <br />liit(1(1 06 1401wNi GA <br />rUpAy�, >c' dit3[ib <br />Facility's Phone: -t,tlF -91A Sf41.cN <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 Wt Not <br />nt lr-K)H&Rfx ikIllAYAR'CxaU!Dt WAJtTE `;;'_rill} i,1�i>`:C't}?tiFhl) i i:.rL., I'Apt.1-1 I- <br />1ALTER;3 - -- — <br />z 2. 1)i �M t ICRA 14AZAF�t4�ta1_ 6 viWA84 L 6()IJD . A88i�F>;UI�N 1 8' t:11L. r1„NI .I lii►��' t rP:l <br />c� <br />Ih 11.4 ER --- — --- <br />3. <br />1 b111(�yLl�f,.. , ; :�id I l.t i- t'',4 <br />15. GENERATOR'S10FFEROR'SCERTIFICATION: (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 labeledlplacarded, and are in all respects in proper condition for transport according to applicable Intemationaland national govemmenlal regulations. If export shipment and I am the Pr maty <br />Exporter, I 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) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is We. <br />Generatoesl0fferor'Signature Month Day <br />s PrintedfTyped Npme <br />� 18. International shipments U Import to U.. <br />Z <br />Transpoder signature (for exports only): <br />W 17. TransporterAcknowledgmenlofReceipt ofMaterials <br />C2 Transporter 1 Printed/Typed Name <br />O) <br />from U.S. <br />Export <br />Port of enby/exit: <br />_ <br />Date leaving U.S.: <br />18. Discrepancy <br />18a. Discrepancy Indication Space � Quantity ❑Type ❑Residue <br />Manifest Refe <br />18b. Alternate Facility (or Generator) <br />J <br />U <br />LL FacilitysPhone: <br />LO 18c. Signature of Allemate Facility (or Generator) <br />a <br />Z <br />N19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling syst <br />W 1 <br />0 <br />20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted <br />in Item 18a <br />PrintedlTyped Name Signature <br />EPA Form 8700-22 (Rev. 12.17) Previous editions are <br />❑ Pallial Rejection <br />EPA ID <br />nth Day Year <br />❑Full Rejection <br />Notice: State of California requires <br />generator to photocopy and mail to <br />DTSC with 30 days: <br />P.O Box 400 <br />Sacramento, CA 95812-0_400 <br />GENERATOR'S INITIAL COPY <br />