Laserfiche WebLink
ii <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3-E7 ency Response Phone 4.Manffest Tracking Number c <br /> WASTE MANIFEST :: :. 4 - 1�.1i}'<!E,6 in �s d� .� �. KV <br /> 5-Generators Name and Mailing Address ' Generators Site Address(if different than mailing a&reis) <br /> Xi+a�f :i3". ill i71 eT iA DI', -k 1:C <br /> ...,. <br /> �i��l.:f�"LSti ���i �._,:..rL�Li•--itilCifj0 <br /> �: <br /> a Generotors Phcme: �r9-a0;: .7,:,..:=J i rsi i, �Jiti <br /> 6.TransNXer t Company Name.. U.S.EPA ID Number <br /> �11�►_.' v-KLIt_IwN 6'L-i1 r.0SiN 1iL <br /> T1LrR'IGi�IL <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address - :• - U.S.EPA ID Number <br /> yy .�E.���T4f i�'� y ��•k j Lf.JCJ� ``409&16'-' <br /> 55 <br /> .J J.�h_.c�1"'�'�tlJ�.' t.40 iJ 16'-- :�'♦J ice• <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 1 D.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) yy--FFrr,' No. Type Quantity Wt.Nol, 13.Waste Codes <br /> 1 f1.'.i I`I' .L_t::� t�Fii,i�s DOIJ� r7r-t.�.3 r.=� ..F �:�i;_, S r >ti'ra <br /> Z 2. <br /> L <br /> C7 <br /> 3. r <br /> 4. <br /> 14.Special Handling instructions and Additional Information <br /> r 4fi1Ci't:. i:Y ._f tRrk` Ott CtCI- i]erver"ctcir, cwifwr,' , alterity' iiav: UF'2 <br /> * t + _ i <br /> 15. GENERATOW&OPFEROR'$C RTIFICATION: hereby declare that the contents of this consignment are fulty and accurately describe above by the proper shipphng name,and are classified,packaged. <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international an4 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 EPA Acknowledgment of Conse - <br /> t.certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator r(b)(if I ao a small quantity generator)is We. <br /> G eratgsrOfferoes PrintedlTyped Name Signabye Montle Day Year g <br /> 1 ational Shipments <br /> il- ❑Import to U-S. ❑Export from U.S. Port of erhtrylexiL <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> a 17.Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> I Transporte21rinWIT"ed Nam: Signature i Month Day Year <br /> 0 - /v <br /> a <br /> z Transporter 2 PrintecTryped Name Signature Month Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type Residue Partial Re1 <br /> ecin ❑Full Rejection <br /> Manifest Referenoe Number, <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> I � <br /> h C.7 <br /> u- Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> F <br />! a <br /> x <br /> I 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> cn <br /> LU 1- 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> I Printed ed Name SignaW Month Day Year <br /> 1 <br /> EPA Fo 00 22{Rev.1217) Pr4vilifus editions are obsolete. DESIGNATED FACILITY OPY <br /> '#-YOU RIVED THIS MANIFEST,YOU HAVE RESPONSIBILITIES UNDER THE e-MANIFEST ACT.SEE INSTRUCTIONS ON REVERSE SIDE. <br /> r <br /> i <br />