|
Please print or type. 41pr / 7 6/1 Form Approved. OMB No. 2050-0039 4 GENERATOR II. UNIFORM HAZARDOUS
<br />WASTE MANIFEST
<br />1. Generator ID Number
<br />( A I) 9 8g B I ot.-)
<br />2. Page 1 of
<br />i
<br />3. Emergency Response Phone
<br />boo .5-.cb ,
<br />4. Manifest Tracking Number
<br />_ JJK - Generator's Name and Mailing Address ,..3 . k. 5 i bmf,) krt. e .,-‘ Generator's Site Address (if different than mailing address)
<br />1-1°419" L.
<br />Lai .-7 ..... • tiv u-d o rviA 'Rd ..
<br /><1533o
<br />Generator's Phone: !. c 0 , 1.....44 ViA .rd (.-4. I.) 2,0 1 41 5.4.0 a -515 -:: I
<br />Transporter 1 Company Name U.S EPA ID Number
<br />..1 -t---', 4-.' 4170-4/ C - i tiC I - 1 1:. 4 -7 14 L)
<br />Transporter 2 Company Name . U.S. EPA ID Number
<br />I
<br />Facilit
<br />Designated Facility Name and Site Address im 41 -.1- ..cit,A,F), tsj P6-c. iviEv --r- __ 4-x-n-te-tal Fk f., U.S. EPA ID Niiirber
<br />Li I L L.) .-_),".._-i L'ii A .j.E, . i VC-TitC Mrt444" CO-/ , 649 i3 2 cf 1
<br />'s Phone: 5 q _Y66, 41-7 1 .7( :
<br />ga. 9b. U.S. DOT Description (includng Proper Shipping Name, Hazard Class, ID Number, 10. Contai ers it. Total 12. Unit 13, Waste Codes HMand Packing Group (if any)) No. Type Quantity Wt No.
<br />1' 'r v 4.•,-Le 501-id k ?I
<br />C eon6-- se i it coy, .. :3) -
<br />
<br />
<br />
<br />14. Special Handling Instructions and Additional Information '-.2
<br />
<br />. •
<br />-list ''''1 I 1 ki "4--- 1 2%',.
<br />0 1' n b. 0 tito‘
<br />-44 2-51 g 0C-1-( .f.
<br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consign/sent 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 national governmental regulations. If export shipment and I am the Primary
<br />Exporter, I certify that the contents of this consignment conform to the tennis of the attached EPAAcknowledgment of consent.
<br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I ass a large quantity generOor) bulb idlani,a, small quantity generator) is true.
<br />Generators/Offerors Printed/Typed Ram ,(4,..,....f.1,71) 1/\-------"
<br />Month Day ,.. Yeac
<br />,r= 0 , , 3ô /1.,,,,,./.:7 ...
<br />...' / I .0 i 4 t .. 1.
<br />F
<br />16. International Shipments Import to U.S. El Export from U.S. Port of entry/exit _
<br />Transporter signature (for exports only): Date leaving U.S.: TRANSPORTER 17. Transporter Acknowledgment of Receipt of Materials
<br />Transporter 1, Printed/Typed Name Sigraturo Month
<br />\5-r - '' +2 //'-: Nik 71,//01-• I
<br />Ddy Year
<br />--2. I
<br />Transporter 2 Printed/Typed Name Signature Month Day Year
<br />I I I I 4- DESIGNATED FACILITY --0. 18. Discrepancy
<br />1--, Discrepancy Indication Space Quantity Type Residue Partial Rejection 1 _, FU L Rejector
<br />Manifest Reference Number
<br />Alternate Facility (or Generator) U.S EPA ID Number
<br />Facility's Phone. I
<br />Signature of Alternate Facility (or Generator) Month Day Year
<br />I I
<br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
<br />1. 2, 3. 4.
<br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as ncted in Item 18a
<br />Printed/Typed Name , .
<br />'
<br />Signature - . -) 7, Month pay. Year
<br />i--ci'\- 101'10._ -K . L .(' \A ()1/4-/ I rs C., I ' ' I
<br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR
|