|
Form Approved. OMB No. 2050-0039 rlease
<br />' "
<br />porn or type.
<br />A , UNIFORM HAZARDOUS I l''Cer*r .'.7 !'-' L'I'2.7rt':'7. ' - ''''''''''''''"' I, ; PanA I nr I 3, Emergency Response phone .1! ..Manifest Tracking Number ,
<br />-- " — L•(-1C.,'L1r, - I SU ',/-• 11' -
<br />ti IA I w^' I — rut-tr,-;-.., • ' - - , - - - - --k- 1 S, It 170.-:::77:109.0,..,,:c,„u 2 2 9 -9 P 4 1 f
<br />Generators Name and Mailing Address Generators Site Address (if different than mailing address)
<br />
<br />9-1•Nr-• e , I .---$ C-- •
<br />
<br />1\,1 • --T--k-VO V-1--17-01-A t'`3.
<br />
<br />0 1 Generators Phone: I.-1 •"- BGL0- 0001 I
<br />Transporter 1 Company Name U.S. EPA ID Number
<br />41-4 o,./ V) O. gr , L--1 r--7 1 C-11)--0-1,-e_>----1 p,
<br />Transpo r2..C,,,rnprn*/2 ;„ ../..../40f../g."4....„) U.SAPA ID Nu r
<br />I( / /IZP- W9W
<br />.---(//Zrif ,,..
<br />Designated Facility Name and Site AddresS .S. EPA ID Number
<br />14,7 __. c:, L,.., . 1 --1 - .4 1--
<br />i tc L...-c."
<br />---(c.;2-51-} ..2_`..S- 4-t S- ICA- 0-2_)/-1- 0=lo A Faality's Phone: c
<br />gb. U.S. DOT Description (including Proper Shipping Name. Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes ga.
<br />I'm arid Packing Group (If any)) No, Type Quantity Wt./1/01.
<br />cc
<br />0
<br />I. !--- \ •=f.r---S - F-C- \-1/4 c)--,, 0 kix \J.,_9
<br />,2 t_ I :--
<br />w . tsr 2.
<br />0
<br />4.-- — ,,,,,,,-;;-, ;
<br />Special Handling instructions and Additional Information ..v.Lc, ricr-s te__ k,....l V a- r-1
<br />t--/ i 1 5-3 1=-2_.04------1 L--e--: Ciq 40 1 I V)5.4\10-- Ps 1, OV. op a-k A-7- a
<br />'--E: 1,31-jr_O 1-1,`+-11:4,4C,, wi, -rt., -224S-
<br />Dg.-D WIS' -__\ r(S?=A: CAroo • I `- .
<br />GENERATORS/OFFERORS CERTIFICATION: I hereby declare that the contents of this consignment are fully end accurately duscnbed above by the proper shipping name, aid are classified, packaged,
<br />marked and labeled/placarded. and are In all respects In proper condition (or transport according to applicable Internationaland national governmental regulations. II 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 Consent.
<br />I certify that the waste minimization statement Identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (III ants small quantity generator) Is true. Year -1"-,..A.E," Signature Month Day
<br />Generators/Offerors Printed/Typed Name ,...Au,s1--1 ,...\ .,.
<br />Ch•-•1'1;;Erl- A t...F 0 F7 prz._,,,,z- 0-1 C... .1* 7.c, 7-1
<br />,_.$
<br />.
<br />Inlimitional Shipments 0 Port of entry/exit 0 Import to U.S. Export from U,S.
<br />TransiSorter signature (for-exports only): Date leaving U.S.:
<br />re 17,•Iransporter Acknowledgment of Receipt of Materials Year
<br />ce
<br />0.
<br />Ira
<br />o
<br />. crier 1 Printed/Ty d Name Signe i Month Day .
<br />s ' P 17 ivilia,1
<br />
<br />k\ I Teat co True
<br />I,
<br />V i
<br />Sig. at .• / 1
<br />Month Day
<br />Namli
<br />
<br />AO ‘ /624P/ ,-44/..• • ' ‘--,.' I 7 DESIGNATED FACILITY 10. aepency
<br />Disc ncy Indication Space 0 Quantity LII Type Residue Partial Rejection Il
<br />Manifest Reference Number;
<br />Full Rejection
<br />Alternate Facility (of Generator) U.S. EPA ID Number
<br />Facility's Phone: Day Year
<br />18o, Signature of Alternate Featly (or Generator)
<br />Month
<br />treatment disposal and recycling systems) 19. Hazardous ante Report Management Method
<br />1
<br />Codes (1.o., codes for hazardous waste
<br />2 3 •
<br />20 Designated Facility Owner or Operator Cerillica ion et receipt of haze can materials covered by the manifest except as noted in Ile a
<br />Yeac
<br />Printed/Tye Signature Month
<br />'1.------ I
<br />Cl ..KtPn r Ar.ti iri in EPA's e-MA IFEST SYSTEM
<br />Day
<br />'251 2-`1
<br />EPA Form 8700-22 (Rev. 1247) Previous editions are obsolete.
|