Laserfiche WebLink
Please print or type.(Form designed for use on elite(42-pitch)typewriter.) Form Approved.OMB No.2050-0035 <br /> UNIFORM HAZARDOUS 1 Generator IfJ Number 2.Page 1 of 3.EmergertcyryryResponse Phone 4.N[anifest Tracking Numiser <br /> WASTE MANIFEST CAC { k , L ` 51 rPC ftp T'�� 00 5 23 2 3 . 9 JJ K <br /> 5.Generatur's Mame and Mailing AddressC4V— 4"-`xp,� L tvto4 moo Generator's Site Address('d different than mailing address) <br /> P ca.b tuba ter- 44A00t4 (fAr t.s%.t3 <br /> Generator's Phone: <br /> 5.Transporter 1 Company Name U.S.EPA ID Number <br /> 7-Transporter Mompany Name U.S.EPAID Number <br /> 8.Designated Facility Name and Site Address n� t_ U.S.EPA ID Number. <br /> Facilitys Phone: <br /> g; 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,10 Number. 10,Containers 11 Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WtlVol. <br /> 1.c1� (O�'S, Q►b11 Pt vET371 ,1.9.E <br /> — - <br /> ,� CiC.'A <br /> ZRON k 0-000 a with- <br /> y. Q <br /> 3. <br /> 4. <br /> 14,Special Handling Instructions and Addriicnaf Information <br /> '506ioy 13SitFil G s4 ] <br /> �r ,c..+,�,�'��-c�S� <br /> 15. GENERATOR'SIOFFERDR'S CERTIFICATION= I hereby declare theatre contentk of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labelediptacarded,and are in all respects in proper condttion for transport accurding to applicable international 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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)('d I am a large quanti tar)or(b)(41 am a small quantity generator)is true, <br /> Generator'slOff�ror's P4nled�Name Signatur Month Day Year <br /> F-- 16 International Shipments <br /> 1:1Import to U.S E <br /> _. <br /> I_J xport from U.S. Port of entryle4t - <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Tri r 1 Pa IedFT�d N me Sig naW ,/ Month Da�yj Year <br /> O1- I k <br /> w Month Day Year <br /> QTran ter 2 Prince yP�Name Signature <br /> 15 _ I <br /> 18.Discrepancy �. I <br /> 18a-Discrepancy Indication Space Ll Quaff ❑Type Residue Partial Refection Full Rejection <br /> ti Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> k Faciiity's Phone: I i'`r` i a - - _ <br /> W <br /> Year <br /> 18c.signature of Alternate Facility(or Generator) Month Day <br /> r—� 19.Hazardous Waste Report Management MaBtod Codes(.e.,ccdes for fl4ardouj viaslrt trE 1,and recycling systems) <br /> O1 2. 3. 4. <br /> 20,Designated Facility Owner or Operator.G"frcation of receipt of hazardous materials covered by the man'dest except as noted in item 18a <br /> PrintedlTypad Name Signature Month Dayear <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. '1SfCNAT ED FACILITY 7O DES'T`J , r I <br />