Laserfiche WebLink
Form Approved.OMS No.2060-0039 <br /> piQase print or type.(Form desi nad for use on elite(1240h) owriter.) 7—Resp000se Phone 4.�Manjfesj Docking Number <br /> UNIrORM HAZAROO i.Generator D Number 2.page 1 of 3.Emmef�en <br /> A 3 <br /> us <br /> SKS <br /> WASTE MANIFEST CAROO r. . 0" <br /> 5.0eperalor'S Name and Mailing Address Generators Site Address(it different Irk <br /> n ma ling address) <br /> r-�Fl.TA TRX. %A'A',.?.,; 'H' <br /> PQ BOX <br /> F&I C N C H' <br /> C.g"rajor`S Phow: U.8,EPA ID Number <br /> 6. rr,I Camper Name <br /> T,Transporter 2Company j4ame U.S.EPA ID Number <br /> B.DesipZpd Facility Name and Site Addrem MTEV(Sr T K 0 o 6c u.s.EPA ID Number <br /> 6000 SOW STRSET <br /> 5ACRAMENTO CA C00008 45 7 <br /> FacitiYE Phone: <br /> T Shipping Name,Hazard Clem,ID Number, 10,Gontshers 11.Total IZ Unit 13,Waste Codes <br /> HM and Parking Group fdany}) No. Type Quantity WLIVOI. <br /> FOOS r003 *POi <br /> DO <br /> X. 'WAVE `INA11hf RELATED MOTF-REAU9, IJNi2b,�, <br /> o pr MIS M�s �12 <br /> tipI !1, �F.P\C-kJ,26) 1.234/6AL(FOO5,FQ03,000J, <br /> 0029,D040) <br /> 'Ot:TE PANT RV�ATED MATERTAL­WMI'63� <br /> LU 20/GAL <br /> 00 6,00,49,0040� <br /> 3. <br /> 4. <br /> Id fpecialH;nlz7Rin.truntiorsandAdditionalinbmatbi, W TRrV,#1Oe46643? 0:1)1 4184166 000037092i) 023 '25 <br /> S y. T9, RZ7rAIN 2 <br /> 15. GENERATDRIS/OFFEROR'SCERITFICATION: I hereby declare Mal tht COT110ts Of Ns 00f"Orneni are fully and accurately described above by the propel shipping name.and are classified,packaged, <br /> marked and lobelediplacarded,and are in all respects In proper condition for transport according to applicable internalionaland nsUonal governmental regulations.I 9KPOM Shipment and I am IAO Primary <br /> Exporter,I certify that the owLents of this consignment conform to the tormsofthq attached EFAAcknowlaigment of Consent, I <br /> I codify that ft waste minimitatbn statement identified In 40 CFR 26227(o)(if l am large quantity generator)or(b)(KI arip-jamal'quantity geneis(or)is true. <br /> Year. <br /> Genorsloes/Offeror's Printed Typed Name Signature <br /> �/ <br /> J&,Irrtqrnsllonal Shipments <br /> 1:1 import to U.S. ❑Export from UA. Pod of entrylexit <br /> Transporter signature(for exports only): Dale leaving U.S.: <br /> 17,11ransporter Acknowledgment of R"pt of Materials Month. Day Year <br /> Transporter I PrntedfTypLd Name Signature <br /> 0 <br /> rf Month Day Year <br /> Z z/ Signature <br /> Transporter 11kWITYPed Name <br /> 16.Disaep=Y <br /> 18a,Discrepancy Indication Space El puanl ly El ve ❑Residue LJ Pjrtiai Rejection L J full Rejection <br /> Manifest Reference Number: U.S. DPA 10 Number <br /> _16—.Ww Tie Facility or Generator) <br /> MOnT Day year <br /> LO _Tk Signature OfAlternale Facility(or Generator) <br /> ------------------ <br /> U219,Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment,disposal,and recycling systems)LU 1 2. 4. <br /> H 3.It� I H141 <br /> 20.Designated Facility Tyner or operator,Carfilicaton of receipt of hazardous materials coveted by IN manifest except as noted in Item I <br /> Ba 1�wa ' ' - Signature Manch Day Year <br /> 7 / <br /> 899-9 TZOI�Ood OGZ_1 916�98HT6 01 ,-81-10 <br />