Laserfiche WebLink
Please print or type. ; Form Approved, OMB No. 205H039 <br />UNIFORM HAZARDOUS 1•'8enerator ID Number , : TP ergency Response Phone 4. ManffestTracking Number <br />WASTE MANIFEST CAC 0 0 3 1 0 8 7 1. o; .� 't t �1;rs 112 ^ JJ K <br />f <br />5.HlMelling <br />t`•�•'�Ck.. <br />:,.•� h$i�Ito Address (it <br />different ngaddress)�CWMM@CCo LLC ater,LLC <br />231 Uftyeb k• Drive <br />TtaCY^4 949 <br />Generator's Phone: 9 2 8 2 8 3- 8 7 7 7 4•S ; "� .7 <br />6. Transporter 1 Company Name a, .pry6*14A, U.S. EPA ID Number <br />to <br />tj 12 VG <br />ind <br />7, Transporter 2 Company Name a U.S. EPAID Number <br />Nam d SltaAddrass <br />�� '�' U.S. EPA ID Number <br />3� Sa"r;F YVM A C..0untf 't,a►�DF+w <br />246 ►9x36 3.. Avc. )vd 19 A i OOC) 6q�0 <br />vY M A , AZ 85365 <br />Factlity's Phone. <br />NOW <br />99. 9b. U.S. DOT Desaipgon (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. To 12. Unit13. Waste Codes <br />HM and Paddng Group (d any)) ' No. Type Quantity WUVoi. <br />+A)on•RCRA Hazardous Waste, Ugttld (tai) & Water Mbdure) �3 <br />0 0 6 1 17 1 d <br />. w 2 <br />06 <br />Malawi <br />3. 4 �. <br />4 • �,;a,�.t <br />as 1 <br />9� <br />SR; # 171 t, allow <br />Invoice Costera Waste & Hnvironmental,.Inc,.• <br />r. <br />15. GENERATOR11OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are futiy and amxxtretely dasaibed above by the proper shipping name, and are classified, packaged, <br />marked and labeledfptacarded, and are in all respects in proper condition for transport according to applicable intemati6naland national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this oonsignme4 conform to the terms of the attached EPAAdknnowledgment of CortsenL ' <br />1 certify that the waste minimization statement ldentified in$CFR 26W(a) (If I am a large quaintily.generator) or (b) (dl am a smog quantity generator) is hue. <br />GenereWs(Offemes Printedfi Name Signature Month Day Year <br />16. International Shipments <br />F, ❑ Import to U.S. ❑ Export from .. Pot of entrylexiL• <br />Transporter signature (for exports only): Date leaving U.S.: <br />MINIBOOM 01110111111111100 - <br />17. TransporterAcknWedgment of Receipt of Materials • <br />Transporter Pdntedffyped Nam SilinalveommooI s Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑Type. ❑Residue <br />i <br />Manifest Reference Number. <br />18b. Alternate Facility (or Genera" <br />J <br />V <br />I Fadlilys Phone: <br />dw 18a Slgnature of Allemate Facility (or Generator) <br />2 . <br />S2 19. Hazardous Waste Report Management Method Codes p.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />� 1. , � 2. 3. <br />4 <br />20. Designated Facility or rtification of receipt of hazardous materials covered by the marmfffes xoe as nded in item 18a <br />P n Name Sig re <br />EPA Form 8700.22 (Rev. 12A 7) Previous editions are obs e. .. <br />• <br />❑Portia! Rejection ❑ Fuli Rejection <br />U.S. EPA ID Number <br />TO <br />