Laserfiche WebLink
Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 013657212 F L E <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> i <br /> .. <br /> •` <br /> V-t <br /> .� - <br /> > <br /> Generator's Phone: _«a.... f «; 'p€,¢.« Y <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 5 es - i. .ec, f.3 4,1 n,sjE t4 L "(}'.' <br /> -4 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number a,i;t <br /> t," S��-'f'� A-feros <br /> 8.Designated Facility Name and Site Address µ$ tn t rt £ f U.S.EPA ID Number <br /> t# <br /> Facility's Phone: •L-t f=w :'' p. <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total " 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> tyt 1. 2it;.-..`fp si3'z�.,S 5 �.` $ .� 3 as.. 's;:.. .2Y ttia> zt2 'p" a"'s >•~- -.1 <br /> r <br /> O - . i ._ r <br /> LV <br /> Z X 2. µ, <br /> W z Y r•x z,F"t z .., 7 x ; s>$ t >a is <br /> x F f}€ A ry <br /> 3. . <br /> t <br /> 4 t <br /> I <br /> 14.Special Handling Instructions and Additional Information <br /> 3d�} A <br /> .z., r ¢ .., 'e, f '•+` '�{3,�0 a{ i '«d =:f ,..t» `. .. ;t...."-i 6 s L 4 ._ f 4 n.a... -.. "'f N^a J;t <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment 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 terms of the attached EPAAcknowledgment 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)(if I am a is true. <br /> n oes/Offeror's Printed/Typed Name Sig e - _ ---- -- Month Day Year <br /> ,J 16. emational Shipments <br /> I- ❑Import to U.S. ❑Export from U.S. Por�t dTtI iry 6 <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> IX LU <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> O <br /> CL <br /> Trans 2 Pnnted/Typed ame <br /> N nature = <br /> � �� � Month Day. Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number: <br /> J <br /> U.S.EPA ID Number <br /> U <br /> Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z <br /> F) 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> w 1 <br /> Q i /V- 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 /> Printed/Typed Name Signature Month Day Year <br /> EPA Form7 - � r <br /> 8 00 22(Rev.12-17) Previous editions are obsolete. <br /> DESIGNATED FACILi T Y TO EPA's e--MANIFEST SYSTEM' <br /> s, s •r ' f..? > f s.,,,, 1 ,,,e -9 - �.x ,,,z...,. 1-7 <br /> Y_ <br /> 3 <br /> t <br />