Laserfiche WebLink
J�(v�7 /T 1537402 <br /> Please print or type (Form designed for use on elite 12-pitch typewriter.) Form Approved.OMB No.2050-0039 <br /> ^ UNIFORM HAZARDOUS':` 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Nanfnal Trucking Nu~ <br /> WASTE MANIFEST �. r ,;d - - ni_s <br /> 000038881DAT <br /> 5.Generators Name and Mailing Address. Generators SSeAddress(it different than mailing address) <br /> SNN KlAfil;lN AERN CJ1LLf1iE SIW ]fiA/6IN lElifl CGLLL(>t <br /> 217.1 Wll G[NTRAL RRXVAT 2111 5WIN Nl1iIL PARMYAY <br /> Generators Phone: AMINIAIN 1111111KIm 41111 11111141 t111411i CA III (784)Sql-"4# <br /> 6.Transponer l Company Name U.S.EPAID Number <br /> 7 <br /> 7.1rrerepanerTCom ny Nane U.S.EPA ID Number <br /> l , e2— <br /> B.Designated Facility Name and Site Address - U.S. PA ID Number <br /> 2lst CeRtg , ERr.irgluNwlal tlaragesleRt 8f Nxvadx; LLC <br /> 2155 <br /> Wil Ar. East <br /> Faclll s Phone: <br /> ga 91b.U.S.DOT Description including Proper Shipping Name,Hererd Class,ID Number, 10.Containers 11.Total 12.Unci 13.Waste Codes <br /> HM and Packing Group(f any)) No. Type Quantity W1Nal. <br /> s 1 filli HASTE 0XIIIZIN6 LINU, TOXIC, N.G.S. iS1lYER NIIANfE, Pill 1115 all <br /> x INRIIA'I eltoiIlEi 5.1 111 P6I1' Willil=iLl! 001 Df OS D <br /> w 2. Iiia INSil 0XIAIZIIN LI/111A, N:6.S. (POIASSION PE To fill 5S1 <br /> % SA F61I RG(1111=lAlLYS) ODJ OF 05 1i <br /> I <br /> 3' Ii1f79i7 WNW f. WSIYI LIg)I115, i/XIC, N.l-5. 10vulIxone ACID, Alli His it? <br /> RJ Sly--1lim 11CI11 1 (4.11 P6II ilwlldl-111E1S1 Opt of: 03 G <br /> 1*1983 Ill fiNll OU LIOUR5, 9-0.5. wI/SENE, IfEXNNEI 3 efiII bill FI/3 551 <br /> t N9iDltl=il/i!S) 001 bi 03 G <br /> 14.Special Handling instructions and Additional Information <br /> 11i 55iA1) ll - E¢6i14i) DXIDIZIN6 T{ixlf, t-i6U 47) 551113 I1 - E116111411 POIASSTUH PEIIHNIJMBV (3) 551614-31 - ER61IS41 <br /> NIMIC Aiii iJ)lilTM i4) SWAM - E/li(l21) ELN1 TLE LAA VIAM (All SGM.) <br /> I 15. G ERATOR'SIOFFEROR'SCERTIFICATION: I heiebydedi thatthe contents of bis cdnegnmerdam filly and arib}efiey dezihed andyetry the'propm sllppng items,and are damned,packaged, <br /> marked and IabehdNplacerded,and are in all respects In proper condition for transport according to applicable international and national grWertknenlal regulations.If export shipment and I am the Primary <br /> Exporter,I certify Nal the contents of this consignment mnform to the teme of the attached EPA Acknowledgment of Consent. <br /> I certify Thal the waste minimization statement identified in 40 CFR 261(if I am a large quentityge ator)or(b)(if I am a sm quantitygenerator)is hoe. <br /> Ceneretory ys Pdntedlyyped Name __ I Month Day Year <br /> _ a IA lv <br /> l Inte <br /> 16. mabona SHencs El from U.S. ort dent t <br /> p- - � ❑Impart to U.S. 7len <br /> z Transporter signature(for exports only): ate leaving U.S.'. <br /> w. 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Pnnledlryped Name Signature- Mora Day. Year, y <br /> IPS'' a dEAt^Nr DA4E �ppVr?A'' - ,- J.e.k..S,n �.R... bra.tm.. g ` Iq 112, <br /> 0R!it !IFOrPn Naele 'Sgnatue ' M4hth Defy Year '1 <br /> iSa,Q'rsc@parlgy Indirako(t$pate ❑ Quantity - ❑Type Residue I—I Partial Rejeden ❑Full Rejection <br /> VodlaEpA�rry <br /> 1St.ANernate Facility Generator) (tote pe`n'St`(iYumber <br /> hos the appfe P <br /> LL FaciliysPhone for, and will accept waste <br /> I w 18C.Signature of Attemale Facility(or GeneralMonth Day Year <br /> a this generator is Shipp^9• <br /> z <br /> F 19.Hard dous waste Rept tliar agementMemedcoeee svnda.w aze denaarea a aaaroM a ckpoca an4 aw s1 <br /> ! <br /> Ct 4. <br /> I -� 2. .� I � I 9. H1�'YI <br /> L� <br /> 20.Designated Facilityowner or Operator:CeNfration of receipt of hazardous materials covered by are manifest except as nded In Item iSe <br /> 11I Printed/Typed he SignatureMonty Day Year <br /> Iv <br /> EPAFonn870022( <br /> �5) vlouseditionsareobsolete DESIGNATEDFACII TO GENERATOR <br />