Laserfiche WebLink
Please print or type. Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generalor ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Traching Number ] �[ <br /> WASTE MANIFEST i �l 1?fl(r,1 t i4)r`t: I ;Fll�i.f+iii},r,1RNY x JJK <br /> til � <br /> 5.Generalofs Nome and Mailing Address Generator's Site Address(if different than mailing address) <br /> ,til,• . I a�� 4!`-�I <br /> Generator's Phone;` <br /> 6,Transporter 1 Company Name U.S.EPA ID Number <br /> V01-t0k '- '4 IJ'tt I Is-vv�I 1 ' Ilk 11'd1 f�1dilF�f121 :'J.rr <br /> 7 Transporter 2 Company Name U.S.EPA IU Number <br /> WLJ41 I NVli 4 Itik t•r Irl ItY :.r:.l t:A+l::ItA, (;AWAX) /5422 <br /> B.Designated Facility Name and Site Addr¢sa U.S,EPA 10 Number <br /> YtIA1n rl:ti:iMli;elF- I)tl�t•1!Gt•I�HFfN;:illi ; n!{arlf,ri�,7tt+t?} <br /> ,,.,t hl r.f I Ilk'.I ITVA) 5,15 <br /> Facili %Phoni a "101 <br /> ga 91 U.B.DOT Description(including Proper Shipping Name.Hazard Class,ID Number, 10.Containers t1.Totat 12.Unit 13.Waste Godes <br /> HM and Packing Group(if any)) NO, Type Quantity Wi <br /> Cr <br /> 1, ".IA414C`.RAiIL7ARI 1<Tt11%VVA:wlfw!,N)lIf1 All )IR 10.441:,, IrA1q;f? of IIN' •rfsli v �:�•' <br /> o <br /> W i <br /> C7 <br /> 3. <br /> 4 <br /> 14.Special Handling Instructions and Additional Information <br /> +'hila-{L41r Ib10o'0:9,41 i:; I'All-*t,:ii h:ILI'frli �-Xrj# if I <br /> FlivIERGErNCY CL*Ii JAIME <br /> 15, GENERATOR'SfOFFEROR'S CERTIFICATION; I hereby declare thal the contents of this consignment are fully and accufalely described above by the proper shipping name,and are classified.packaged. <br /> marked and Iabeledlplacarded,and are In all respects in proper condition for lransporl according 10 applicable international and national gavammental regulations.If export shipment and Ian)the Primary <br /> Expoler,I certify that the contents of this oonslgnment conform to the terms of the attached EPA Acknowledgmerit of Consent, <br /> I certify that the waste minimization statement idenlriied in 40 CFR 262,27(a)(if I am a large quantity generator)or(b)(ifI am a small quantity generator)is true. <br /> GeneraloesfOfferoes Psinfecirryped Name Signature Month Day Year <br /> 16.international Shipments <br /> ;L.- ❑Import to U.S. ❑Export from U 5. Port of entrylexii: — <br /> Transporter signature(for exports only); Dale leaving U.5.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> W <br /> I— Transporter 1 jPrintedfrypyeddNaame Signature Month Day Year <br /> rim. �� r''T I. <br /> Transporter 2 PriniWITyped Name Signature Month Day Year <br /> H <br /> 1B.Discrepancy <br /> 18a.Discrepancy Inditation Space ❑ QuantityType <br /> ❑ ❑Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Fadlity for Generator) U.S.EPA ID Numher <br /> _1 <br /> U <br /> lff Facility's Phone; <br /> W 1&.Signatlue ofAtlemaie i(or Generator) Month Day Year <br /> 19 HaEardcus Waste Report Management Method Codes(i.e„codes for hazardous waste treatment.disposal,and recycling systems) Notice:State Of California requires <br /> 0 1. 2. 3. generator to photocopy and mail to DTSC <br /> within 30 days; <br /> 20.designated Fatality Owner Of Operator.Certification of receipt of hazardous materials covered by the manifest except as ndled In Item 18a P-0 Box 400, 5a cra men to,CA 95812.0400 <br /> PhntedlTyped Name Signature <br /> EPAForn1870D-22(Rev,12.17) Previous editions ere4155o1eie. GENERATOR'S INIIIAL L;i <br />