Laserfiche WebLink
(. PENN-VLVANIA DEPARTMENT OF ENVIRONMENTAL PRr TECTION <br /> t_ I 1" Bureau of Land Recycling and Waste Managerne <br /> P.O. Box 8550 logo Form approved. <br /> 2500-FM LRWMW51 REV.7/99 Harrisburg,PA 17105.8550 OMB No.2050-0039 <br /> OFFICIAL PENNSYLVANIA MANIFEST FORM <br /> UNIFORM HAZARDOUS 1.Generators US EPA ID No. Minn.., 2.Page 1 mmrmauoa within the bola red border is <br /> omumenl No. of not required by Federal law but may be <br /> WASTE MANIFEST _ rrt; required <br /> estate law. <br /> 3.Generators Name and Mailing AEdreaa - i A Slate Manifest 0ocuin <br /> nt jiumber <br /> rilkiagton North Awerica, Inc. PAG T5^4 <br /> SILO <br /> E. LrOuiS3 AVE. <br /> LathrOlD, rA 30 <br /> 4.Generators phone C e.state Gen to <br /> 95 <br /> 5.Transporter 1 companiffthie - fi.US EPA ID Number O.'Sfty Tran..10 <br /> PA-AH <br /> 7.Transporter 2 Company Name' '-- , ,E A D Number 0,Trame5poners Phone I ) <br /> E.Stets Trans.l0 '' •• — <br /> 9.Designated Facility Name and Site Address 10,US EPA ID Number PA-AH <br /> LPC \.CQPI, Ii11�.. F.Transporters Phone ( J <br /> 591 Mitr,heall Avenue <br /> G.State Facilitys ID <br /> 11< rt own, P. 16103Lin &73E71 +> H.FacilitysPhone <br /> l.-. .1 <br /> 12.Containers 1J. ^ I. <br /> HM 14. <br /> 11.US DOT Description(Including Proper Shipping Name,Hazard Class,and ID Number) Total 14. Wawa Na. <br /> a l No. Type Quantity wwol <br /> t7jAZA`WOUS :YT?1,ISV: .'JJLIC . .tx <br /> `?A31377, Ili (Mtzrcury 1 G 17? r j ? :r03l <br /> G a <br /> E <br /> N <br /> E <br /> R e. <br /> A <br /> T <br /> O <br /> R <br /> a. <br /> TJ <br /> J.Additional Descriptions for Materials Listed Above K.Handling Cotler for Wastes Listed Above <br /> 11 . a. Mercury containing Dtianr,is a. d. <br /> a <br /> 15.Special Handling InstruInformationona and Additional Information b. <br /> 24 .FLOUR TI A`1SPOR`,AiIOCdEA3e^.i1t,T'at Y COi'd'lA'"T INPOTRAC (800) 535--5053 <br /> Ill AFRC AS RECISTRAnIT <br /> 11 1, material 193tinac3 fOr recycling <br /> 16.GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consigmt ar <br /> nene fully and accuratelyy described above by proper shipping name and era D <br /> classified,packed,marked and labeled and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. <br /> If I am a large quantity generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to me degree I have determined to be economically <br /> practicable and that 1 have selected the practicable method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human health and 17 J <br /> the environment;OR,it I son small quantity generator,I have made a good faith effort to minimize my waste generation and select the best waste omen method that is available <br /> to me and Nat 1 can afford, management <br /> Printed/Typed Name <br /> Signature MONTH DAY YEAR <br /> T 17.bunsionAr 1 Acknowled a ent of Receipt or materials � <br /> A Printed/Typed Name Signature MONTH DAY YEAR N - - . t. <br /> a <br /> A 19.Tran er 2 <br /> PcknowleE a em of Recel t of Malatlals <br /> P <br /> T Printed/Typed Name Signature <br /> e MONTH DAY YEAR <br /> R <br /> 19.Discrepancy indication Space <br /> F <br /> A <br /> c <br /> LL 20.Facility Owner or Operator,Certification of receipt of hazardous materials covered by this manifest except as noted in item 19. <br /> Printetl/iypetl Name SI natureg MONTH DAY YEA <br /> EPA Form 8700.22(Rev.9/88)wemous eeulom are oesolele <br /> CnpY R _ r 1 nlGonTnn. oi-rAul rr rl n <br />