Laserfiche WebLink
Please print or type Form Approvers OMB No K-550-0031 I <br />gAROM HAZARDOUS Manifest Tracking Number <br />STE MANIFEST <br />' Ufa^•. - <br />C,.mpany Name u S EF:, lD'J_mbe' <br />W <br />r- <br />0 <br />CL <br />ZLansD�n!' < P"°ilc''yp='d rvam.i <br />Q <br />f- <br />18 Discrepancy <br />78a Dlscrepanry Intlica110n Space _1 Q„anlrty IJ T" <br />18b alternate Fac ktyfor Generates) <br />_J <br />V <br />LL. FaC10t'% s Phone <br />LJ Export from U $ <br />t,:re <br />U Res due <br />Mande<t Reference <br />18c. Signature of Alternate Facility for Ueneralorl <br />19 Hazardous Waste Report Management Method Codes If e., codes for hazardous waste treatment, disposal, and reeve ng i, -, <br />2 3 <br />u''+gnated Faahty Owner or Operates Certification of receipt of hazardous materials covered by the manifest except as nciej',r ::el' <br />ned Name Signature <br />EPA Form ki, _ <br />'Rev 12-17) Previous editions are obsolete <br />�� P3 tea, tiblcctm. <br />Li S EPA ID N'.,mber <br />9 <br />GENERATOR SNIT I, <br />f <br />1 <br />GENERATOR S'OFFEROR'S CERTIFICATION: ', signmenl are f.. , <br />Lerllf'j thal ,t to haste mi. n._a.Un state nie'i, jef ' <br />.p,..,.e,. 7.. __ game <br />1 - <br />r - <br />W <br />r- <br />0 <br />CL <br />ZLansD�n!' < P"°ilc''yp='d rvam.i <br />Q <br />f- <br />18 Discrepancy <br />78a Dlscrepanry Intlica110n Space _1 Q„anlrty IJ T" <br />18b alternate Fac ktyfor Generates) <br />_J <br />V <br />LL. FaC10t'% s Phone <br />LJ Export from U $ <br />t,:re <br />U Res due <br />Mande<t Reference <br />18c. Signature of Alternate Facility for Ueneralorl <br />19 Hazardous Waste Report Management Method Codes If e., codes for hazardous waste treatment, disposal, and reeve ng i, -, <br />2 3 <br />u''+gnated Faahty Owner or Operates Certification of receipt of hazardous materials covered by the manifest except as nciej',r ::el' <br />ned Name Signature <br />EPA Form ki, _ <br />'Rev 12-17) Previous editions are obsolete <br />�� P3 tea, tiblcctm. <br />Li S EPA ID N'.,mber <br />9 <br />GENERATOR SNIT I, <br />