Laserfiche WebLink
S'(j5 ')S-6'nej ('0_1 <br /> t <br /> Please punt or type.(Ferro designed for use on elite(12 pitch)"writer) �l• �'�) GV-601- <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS <br /> 1.Generator ID Number 2.Pane 1 o E ergency Response Phone 4.Manifest Tracking Number {( <br /> WASTE MANIFEST .:k%n(1`711:r'r' 1-$1dt11 '�t>J• I/'W1 (� SKS <br /> 5 Generator's Name and Mailing Address Generata's Site Address(if different than mading address) �+ �+ <br /> Generators Plane: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> tNN a�1rl:it�'30 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> a.Designated Facility Name and Site Address r U,S,EPIC ID Number <br /> ,r <br /> Facility's Phone <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)) No. Type 13 Waste Codes <br /> Quantity ftlioi. <br /> 1 <br /> i <br /> Z 2. <br /> W <br /> U <br /> 3. <br /> d <br /> 14 Spedai Handling instructions and Additional Information <br /> r'4 HP i=Mf �t h� fi0k)-4hFi <br /> t G OR S CE !f Sia that the oDhTer 'of 'constgnmern'are 3 acdr ey' the proper shipping name.and are clesstfled.packaged, <br /> marked and labetledlplacarded,and are in all respects in proper condi8on for transport according to applicable international and national governmental regulations.if export shipment and I am the Primary <br /> Exporter,I cemy that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimltation statement identified in 40 CFR 262.27(a)(if I am a large quantity generate)or(b)(if I am a small quantity generator)is we. <br /> Generator'siOlferors Typedpama Signature Month Day Year <br /> 16 International ts <br /> Z Import to U 5 ❑Export Irom U S at of entry/a, -- <br /> Transporter signature(!or exports only) Date leaving U S.. <br /> X 17.TransponerAcknowledgmer t of Receipt of Materials <br /> O iransponer 1 f1tinled/Typed Name:1 Signature <br /> Month Day Year <br /> CL <br /> � r k <br /> �Z Transpo t me ped NaSigna re Month Day Year <br /> 15.Discrepancy <br /> 1 Ba.Discrepancy Indication Space <br /> Quantity ❑Type ❑Residue u Pd7Udl Refection ❑Full Rejection <br /> Manifest Reference Number, <br /> 18b Alternate Facility(or Generator) U S.EPA ID Number <br /> U <br /> u- Facility's Phone <br /> L 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> H <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codas{i.e.,codes forhazardous waste treatment,disposal.and recycling systems) <br /> o ' 23 s. <br /> 20.Designated Facility Owner or Operator,Certification of receipt of hazardous materiab covered by Cue manifest except as noted m Item 18a <br /> "eVylied Name Signature Month Da ear <br /> EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />