|
Form Approved. OMB No. 2050-0039
<br />ICICIQG
<br />A
<br />I.J1l1 It VII 111/V.
<br />UNIFORM HAZARDOUS
<br />WASTE MANIFEST
<br /> 1. Generator ID Number
<br />AC JO I 5-&ti 2. a_
<br />2. Page 1 of
<br />2.4-
<br />3. Emergency Response Phone
<br />i fay 6 z-t( ( 3 6
<br />4. Manifest Tracking Number
<br />019703952 JJK
<br />Generator's Name and Mailing AddressF>e _ -1-- ,f ..1 (e.„..), ..,..,5 Generator's Site Address (if iron mailing addres
<br />24 e..4 l:c.) (-fel.' -,5c ," r cA
<br />2r.,:6 • 7 5- 0-,,....71,A k is. r a
<br />
<br />ICA 4 17 -7 -rrice y c A
<br />Generator's Phone(( ( 0 \ -2...( 3 -44 51 / 1
<br />Transporlec75ompanyTJame U.S. EPA ID Number
<br />( c,k. (I'd EP tot roltne,4 itf-4 e rv 1 c"j I CADOS3 CC.--1.1
<br />Transporter 2 Company Name U.S. EPA ID Nimber
<br /> (A.vusr.t.t IA1)6,- 0 ue , c cc I 0 ttli,-66,ag'n-.6q 3
<br />Designated Facility Name and Site Address C ro& )34 cr ,,,,i °LA./At, rl US. FPA In Number
<br />k G Zo Li l 7 4-1‘ S(
<br /> rNeer 1-, c A --
<br />Fac lily's Phone:i‘c"..141--1?-1---7--E--,-4-6T--- cce 2 - 1-fT2, - Sq Lic .1 {A 0 2e 6-10c101q
<br />9b. U.S. DOT Description (includng Proper Shipping Name, Hazard Class, ID Number, 10. Containers li. Total 12. Unit 13. Waste Codes ga.
<br />44 and Packing Group (if any)) Na. Type Quantity 11l1t1Vol.
<br />re 1. nO" RC 0 X 41'204 c3c, 1-----c .5 (4 S `" (.C) , 36-1 0
<br />2
<br />ut, /c) ,i.c i ) CY3 1) A ‘0 0 c
<br />w
<br />z
<br />ku
<br />2.
<br />(..7
<br />,
<br />3
<br />4.
<br />14. Special Handling Instructions and Additional Information
<br />fr S-g
<br />6)-1,-516(
<br />1-14 I/ - 22 -0C-)10 a--
<br />15 GENERATOR'S1OF FEROR'S CERTIFICATION: thereby declare that the contents of this consignment are fully and accurately described above by (he proper shipping name, ard are classified, packaged,
<br />marked and labeledrplacarded, 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 EPA Acknowledgment of Consent.
<br />I certify that the waste minimization statement Identified in 40 CFR 262.27(a) (if 1 ern a large quantity generator) or (b) (ilium a small quantity generator) is true.
<br />Generator's/Offerors Printed/Typed Name Sig;stt&y,......__ Month Day Year
<br />I I I '"Z- I 7
<br /> on l'ke I ( 0 ( Per's- 11.c 13._ (do U. 1
<br />IS. International Shipments I Export from U.S. Port of entry/exit: Import to U.S. .1
<br />Transporter signature (for exports only) Date leaving U.S.: "RANSPORTER I I Transporter Acknowledgment of Receipt of Materials
<br />Transporter 1 PrinrcifTyped Name Signal Month Day Year
<br />r2D ,.._ LiC.3 LEJL i i't,e 't I F I z-
<br />Transp . 2 Printectriyped Naive C
<br />S nature Month Day Year Sr
<br />I ill LA. In 12_ gl 23- - DESIGNATED FACILITY -÷ Ii Discrepancy
<br />18a. Discrepancy Indication Space Ouantky [1 Type El Residue LI Partial Rejection Full Rejection
<br />Manifest Reference Number:
<br />18b.A1Mmate Facility (or Generator) U.S. EPA ID Number
<br />Facility's Phone. I
<br />18c. Signature of Alternate Facility (or Generator)
<br />. Month Day
<br />I
<br />Year
<br />Hazardous Waste Repel Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
<br />1.
<br />f LI I
<br />2. 3 4.
<br />v
<br />ignaled Facility Owner or Operator_ Certification of receipt of hazardous materials covered by the manifest except as ncted in km 18a A). es
<br />Printei +Typed Name
<br />S S 1 (a
<br />I Signal a Month Day Year
<br />s,17W 1 I a-- 11 n7 OVOTdLI- Iii
<br />EPA For 8700-22 (Rev. 12-17) Nevi° editions are obsolete. DES I GNATED.•....,_,.trA,s e-. n r irr ro I I&tvi
|