Laserfiche WebLink
��, t ,• � a`4 { � �n���t S , <br /> Please. HA'f�type." . Form Approved.OMB No 50 0039 <br /> IftlikPAM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone- 4.Manifest Tracking Number <br /> WASTE MANIFEST C A R 0 0 0 2 8 5 9 3.2— ,. _.1 019759533 JJ K <br /> 5.Generator's Name:and Mailing Address Generator's Site Address(if different than mailing address) <br /> LSF De"111111 A Of PLOW HOM z T"18 1*A6110f1t FQCIN I <br /> 13M MarkiA St ME 210 SM W.1lerr*b Rd <br /> 11 Famefto CA 9002 Titicy CA M77 <br /> Generator's Phone: A l A It R 7 R tam 7 <br /> Inc. N ke 21-I' S <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.j jjJJJftt*Wd Site Address U.S.EPA 10 Number <br /> 180 W.Marft AVIRMO <br /> BIDGM tl CA 92316 <br /> Facility's Phone:909 421.2012 C A Q 9 8 2 4 4 44 6 1 <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.Nol`. <br /> WOM 221: <br /> z <br /> UJ <br /> t9 <br /> 3. <br /> 4. <br /> p i <br /> p>;r,;7 <br /> ti ons and Additional information <br /> i4 Special Handling Instructs � a�. VVUW <br /> T r <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,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and natiolLal govemmental 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 /> I certify that the waste minimization statement identified In 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if.118 aymall,qu,ntity generator)is true. <br /> 7s/Offemr'sPrinted[Typed Name ..! Signature Month Day Year <br /> FE 1311 J1 <br /> 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for.exports only): Date leaving U.S.: <br /> 17 TppporWrAcknowI0gmehtof Receiptof Materlals <br /> .., <br /> rahsporter l P' Na, ..SignatuA'O'-7� <br /> Month ay Yean <br /> 1 . <br /> 2C 'Tra ypedName SignatureMonth. Day4Ve <br /> F- <br /> 18.Discrepancy r <br /> 18a.Discrepancy Indication Space 1:1 Quantity El Type Residue ❑Partial Reection ❑Type j full Rejection <br /> Manifest Reference Number:-:., <br /> 18b,AlterirateFacility(or Generator) <br /> Number <br /> J_ wAn •.,� _,- =.r r'.'+J",.: 'rr+wt.e!f!i%w�..y$i�'r3'• a c,: <br /> V <br /> 4' Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes fpr hazardous waste treatment,disposal,and recycling systems)- <br /> 3. 4. <br /> 20.Designated F$cilityOwner or OperatorsCertifica` ipt of hazaidousmatedals covered by th6!manifest except 2s n m ak ti <br /> Pnnted ed Name Signature Month ' Day Year <br /> r: <br /> , t t, Z P <br /> EPA Form 8700. 2( e1:1217) Previous edits olete. DESIGNATED FACILITYTO GENERATOR <br />