Laserfiche WebLink
tl <br /> Please printor type:(f=orm 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. Manifest Tracking Number <br /> WASTE MANIFEST ,. - •. $ 3 JJ K <br /> -. r t ate. " 3 <br /> 5. Gene ator s Name and Mailing Address Generator's Site Address (if different than mailing address) <br /> KAP ' M CRO WORKS <br /> NO Box 91rui <br /> F Irf € <br /> 2373 � MARIPOSA ROAD <br /> Generators honer TX ' 11 2 STOC�: TON t " I <br /> g �� � 3g <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> 1 c tl - 5 .1 <br /> LA <br /> 7. Transpo er'2 Company Name U:S. Eto ID Number <br /> 8, Designated Facility Name and Site Address U.S. EPA ID Number <br /> WOU41H # ? 1"3 F AVE NU . <br /> l ;k �tNGELE,�� tea 490058 <br /> Facil s phone: 7 A is 0 0 `,o 0 3 0 9 <br /> ga• =U.S. DOTtion (including Proper Shipping Name, Hazard Crass, ID Number, 10. Containers 11 . Ttal 12. Unii <br /> HM any)) No. Type Quantity Wt.Nol, 13. Waste Codes <br /> Q00 ) I t z € R � %t `� +1 �`+rf`Yyga (�S WASTE T , t• i>} $iy 1'1tf 1' � �"}�i { `- .L• � z <br /> I4t{ !14 I �Sr'Gl� tl kT.�ii,-.�'i[ k Ea' ll4d 9 �IU F��i p �i tk lF �{ Lr* '�t14P. i a? ilf..P��3} <br /> W 1 <br /> 44 3. <br /> 14. Special Handling Instructions and Additional Information <br /> ABS€`RBEINI'O SWEE POO AII101 �, :k APPRO RIA <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br /> marked and labeled/placarded, and are in all respects in proper condition for transport according 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 certithat the waste minimization statement ment identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br /> Generator's/Offemes Printed/Typed Name Signature Month Day Year <br /> p 9 ( ' , <br /> Trans ortersi nature fo e <br /> Z ❑ Import to U:S. ❑ Export from U.S. Port of entry/exit <br /> _ 16. IntemationalShipmentsx orfs only): -- - - - - -- - - - <br /> p y) Date leavingU.S:: <br /> W 17. Transporter Acknowledgment of Receipt of Materials <br /> 9 Tmnsporter ,l �Printed/fyped Name Signature Month Day Year <br /> Z ITansp' rter2vnntedlT <br /> < Po typed Name Signature Month Day Year <br /> 18rl8b, <br /> Discrepancy <br /> Discrepancy Indication Space <br /> ❑ Quantity ❑ Type ❑ Residue <br /> ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number. <br /> Jt <br /> Facility (or Generator) U.S. EPA ID Number <br /> J <br /> U ' <br /> Facility's Phone: <br /> W 18c. Signature ofAltemate Facility (or Generator) Month - Day Year <br /> w19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> 1 . 2, 3 4. <br /> 20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/fyped Name Signature Month Day Year <br /> EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete,4;1 1 GENERATOR 'S INITIAL COPY <br /> 'i <br />