|
06 / 11 / 2021 1 : 55 PM FAX 2090488625 AMC'E SAW 121 0001 / 0004
<br /> Pjifse prink'or type. Forth Approved. QMB No, 2050-0039
<br /> lea
<br /> UNIFORM HA7r4RppUg 1 . Generator Ib Number 2, Page t of ,3. Emergarrcy Response Phone 4, ManifaslTran ng Number / ^. p C r
<br /> WASTE MANIFEST ' CALOOOf1 '1d� ! 80i3 r�tE3�f44J 006148405
<br /> t� F:] (� t
<br /> 5. Generators Name and MaBingAddrese Generators SitaAddrass (if dlffereni'ihen mailing address)
<br /> A60ir: SAW
<br /> 1204P F; MAIN, 8,1
<br /> GeneratorePhon �, . _ r olaoc,l0;. N , LA 9520$
<br /> 5, Transporter 1 Company Name U.S. EPA IQ Number
<br /> AlVif.WRICAN VAi. ,,' •f wA:i mL 01L , MI. �fiRtAU(i�7 ?,iU2
<br /> 7. Transporter 2 Company Nama Us. EPA ID Number
<br /> ,�,T'C+ IZi ryCt,j tsPl~:CIAL I"Y '1YAS t'k 60NLt71 I>L1I>x.4 , Iiyo 87Ct f4�fi]R7 ix9 �-1
<br /> B. Dasignatod Pacilly Name and Site Address U.S. EPA ID Number
<br /> GIvRfl*V4NfV%0I1:) + )Ri?i�lf/ ti, Lino , �f�.G£iBQc�sr11�3
<br /> 1 laser, wflrrE M;K 136 ,
<br /> Fatlu sPhoneOl (;P&35'1 •d1<J8Q
<br /> 8b. U.S. DOT Dosctiption (including Proper Shipping Name, Hazard Class, ib Number, 10. Containers 11 . Total 12, Unit 13, Waste Codes
<br /> HM and Packing Group (Ifany)) Na, Typo Quantity Wlivol.
<br /> 1 , io U001 C7OUI 33 €
<br /> fir , tird'l 4 ltltA 'ri 1. APli lfl'tiL1Lt' f_1t�t 4; 4:1;; , >+3. �� . . , i}twit , 00A 940&0 C1
<br /> t f��w�t. flvl� • r)1f. g�
<br /> w
<br /> 2,
<br /> t9
<br /> 4.
<br /> 14, Special Handling Instructions and Additional Information
<br /> PTWFI�Ett 46857�U3 + SA i , ~'rIk .r.' lvca #9 ti3
<br /> f-,K;ERGENC'1 C(WAC1': MARY
<br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I homby declare that the contents of this Consignment are fully and accurately desotbed above by the proper shipping name, ar(f are classified, packaged,
<br /> marked and labeledlplaosrded, and am 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 EPAAcknmvlodgment 4i Consent. ' A .
<br /> I certify that the vtaste mkninrization statement identified in 40 CFR 262.27(x) (if I am a large quantitygenerator) or (b) (if Pam a small quality genCFslo1 ) fs1re. q
<br /> GCItCrdtorsJQffrOr Pri<trtedfTyped Naha ^ i� Signatrua y+ /jttI
<br /> Ve
<br /> jl Mor)tI Dayn A4 Y6�a�•�
<br /> ` . 0 t y,11 �/ � , � ly Jf�F.el, 3 r l
<br /> F 16, International Shipments © Import to U.S. ❑ Expott from U.S. Port of entNlexit; C
<br /> Z Transporter signature (for oxporis only): Date leaving U.S.:
<br /> W 17• TransporterAcknowledgmentofReceipt ofMaterialsW Atilt
<br /> t— f SI not re �� " . " r Month Da Ye
<br /> Transpos44
<br /> Get er, lite ed Name i r '/ : p:-- - , , „
<br /> . ���. . � ex
<br /> Itrar&orterYPdnted/Typed Name �•-^ gignaI Mofilh Day fe'ea
<br /> t-
<br /> 18, Discrepancy
<br /> '16e. Discrepancy indication Space El Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Reiectidn
<br /> Manifest Reference Number.
<br /> 15b, Alternate facility (or Generator) U.S. EPA ID Number
<br /> LL Facvity's Phonic;
<br /> W- 18G. Signature of A ltemete Facility (or Generator) Month Day Year
<br /> U5 19, Hazardous Waste Report Management Method Codes (he., Codes for hazardous waste treatment, disposal, and rewang systems)
<br /> 1
<br /> 2h 31 Notice: State of California requires
<br /> generator to photocopy and mail to
<br /> 20. Designated FadUty0vrner cr OpBmlat Corti6cation of recelpt of hazardous materials covered by the manifest except as noted in IIN i8a 17TSC with 30 gays :
<br /> Pdntad(fyped Name signature P, O SOX 11.00
<br /> Sacramento, CA 95812-0400
<br /> EPA Form 871]0-22 (Rev. 1247) Previous editions are obsolete, ^ t� . OPERATOR'S INITIAL COPY
<br /> r7 S . ri
<br />
|