Laserfiche WebLink
e Please print or type �• <br /> UNIFORM HAZARDOUS 1 G <br /> WASTE MANIFEenerator ID Nu bar <br /> ST <br /> 5,Generators Name t'h1-00(i ti <br /> M�uNE( and Mailing Address 2 Page 1 of 3.Emergency Response Phone Form <br /> 5701 PR N�'� - /.ManifestTrackingNumberoved.OMENo.2150-0039 <br /> �roNrc�RY r�A Q <br /> TRACY RKWA;, Generator's Site Address(if different than "A 6 9 8 5 J J K <br /> Generator's Phone'�37! mailing address) <br /> 6.Transporter 1 Company Name <br /> 1©R ENVIRC�Nr,, . <br /> 7,Tronepo'or 2 Company Neme 2�1 <br /> HAZARDOuS�l� -stip, U.S.EPAIDNumber <br /> 6.Dealgnated Facility Name and 1:1 t r� <br /> SAMEX R �NSPORTATION• CAU981 <br /> ECy 4lhl�, tom,, U.S.EPA ID Number <br /> LUNG TECHNOLOGIES f'`` b <br /> TAIJUVV A"Vr-CINAI N0.3%2,co _V' I A'DE C.V. <br /> RC 22330- A1L1 F REDON[� U.S.EPA ID Number <br /> Facill 's Phone: <br /> 9a. 9b.U.S.DOT Description(Including P 646?4.1! 02-1V 13-1 n <br /> HM and Packing Group(if any)) 9 roper Shlpping Name,Hazard Class,ID Number, <br /> 1, 10.Containers <br /> 11.Total 12.Unito RQ UN 1 183,WA,' N0 Type Quantity WLNoI. 13.Waste Codes <br /> P41(DW),EftO „t-uI Ana),;1, <br /> ut1 0001 <br /> Z Z. per ' <br /> 0 FtQ UN9175,Wry�iJru;cvntaM11t1g HamtTlat�la Ilqul�,nA.s. Is DlF's, <br /> 01YMII4.1.I-7rlI <br /> LF &00 3/w 362 DOUt <br /> 3. <br /> 4 <br /> 14.j Special Handling Instructions and Additional Information I� <br /> 1.)Appric <br /> A. Appmv.-ii k.sy + fjlAG AlaSJId21LII MIXED Sill <br /> -VENT(---4_�_.±-_._ )AUlgr�10222E24001 <br /> rRv�o2(r'�? 3 C.EV-- RF_IIv112�� <br /> 15. GENERATOR'SIOFFEROR'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 inlemabonal 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 I am a large quantity generator)or(b)(if I am a small quanfity generator)is true. <br /> Generator's/Offeror's Pdnted/Typed Name Signature Month Day Year <br /> 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entrylexfl: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> LLI <br /> Transporter 1 Printed/Typed Name Signature ��� Month Day Year <br /> o lit 7 LS <br /> Signature Month Day Year <br /> Z Transporter 2 Printed Typed Name 7 Ie <br /> 18.Discrepancy Residue Partial Rejection <br /> F.11Rejeclioo <br /> _- 18a.Discrepancy Indication Space ❑ Quantity ❑Type <br /> ❑ ❑ <br /> Manifest Reference Number: <br /> EPA ID Number <br /> 18b,Alternate Facility(or Generator) <br /> JYear <br /> Month-Da y <br /> U <br /> u-- Facility's Phone: <br /> 0 18c.Signature of Alternate Facility(or Generator) <br /> W <br /> Q <br /> Z � <br /> (7 3. f <br /> N 19 Hazardous Waste Report Management Method Czdes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> L J 1 f' Year <br /> rJ (7 Month 0aY 2 <br /> Signature <br /> 20,Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item AGILITY TO GENERATOR <br /> Printed/Typed Name DESIGNATED F <br /> obsolete. <br /> EPA Form 8700-22(Rev.12-17) Previous editions are <br />