Laserfiche WebLink
Please print or type.(Form designed for 2L22 <br /> elite(72-plch) ewrlrs,)7J 16fl0107517 �PPW 1/20!2018 FolmApphave tl.OMB No,2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2 Page t of 3,Emeryency Response Phone 4.Manliest Tacking Number <br /> WASTE MANIFEST CAR 0 0 0 2 2 555 5 7 (1300}.483-3718 FLE <br /> 5.Generators Name end Mating Address Generators SNAddreu(ddlderenl than mailing address) <br /> YRC Ino d.b.aYRC Freight <br /> 't 0990 Rnp Asrp <br /> Overland Park.IIS 66211 —1535 E-'--1.Pesnde a Ave <br /> Generator's Phone: 120918334300 ATTNJarrrie Haines Trae'r,C'A 95304 <br /> 8.TTrmponfer 1 Company Name U.S.EPA ID Number <br /> Clean Harbors Environmental Service,Inc. MA D O 9 3 2 2 2 5 0 <br /> 7.TanspoMr2 Company Name U.S.EPA ID Number <br /> 8.Designated PadGty Name and Ste Addreu <br /> Clean Harbors AraAanite LLC U.S,EPA ID Number <br /> 11600 North Antos Road i1 T D 9 H 15 5 21 7 7 <br /> GrantsAlto.UT 84029 <br /> Facil(a Phone: Ya'>Fa x:u1 va nn <br /> ga, 9b.U.S.DOT Description findudng Prom Shipping Name,Hazard Class,ID Number, <br /> 10.Comalnea 11.1bud <br /> Quantity <br /> 12.Urc <br /> WINN. <br /> HM and Packing Gaup(harryJ) No. Type Quantity WWoI. 13,Waste Codes <br /> a t' UN1993.WASTE RAMMABLE UQUI0$,N_O.S.,(ETHANOL.METHANOL),3.PG It �� D� Ui54 D001 331 <br /> 5t 41,5 <br /> w- <br /> 2. RF$1011F;145Tl:f)NTAINFf�i1Ni 593,1>JlCIIf QJ{[-pjN�'Tlllfgl�lE. 513 <br /> X 8.1-P4al11 <br /> 3. <br /> 4. <br /> 14.Special Handling InsWctions andAdd'nal infatuation iSlBB X3515 <br /> 1-CH1125995 /�5�r ERGff128 <br /> •2_CH1125710 ERG#l60 <br /> IS. GENERATOR'S/OFFFROR•SCERTIFICATION:I hombydeclza that the contents OffNacorsignmentaafully and soarrakty described above bythe pmper shipping nam a,and are dassMed,packaged, <br /> marked and lebeledlplacarded,and are In at aspects In proper condtion fwbansporta eOrding to applicable International and national govenunimtal aguladons Ilexpwt shipment and 1 am the Primary <br /> Exporter,I certify be the contents of this camigna ent conform to the terns of the attached EPAAdmoviedgme t of Consent --� <br /> I canny that Ne waste miMMxation statement ldemifred in 40 CFR 26227(a)If l ami large quwfifygeneretw)of(b)(if l am small quantitygeneatar)is hue. <br /> GeneataY eats Pf ype0 ame gni ere n ay ear <br /> Srct 2 <br /> ,LA 1 <br /> r 16.Intematlonal SNpments <br /> LJ U. .S ❑ratpatfromU.S. a <br /> U,SPdoen <br /> flry/exih _ <br /> F- f <br /> z <br /> Transporter sinature fisc ns wlyhDaM teal U.S.: 1J <br /> � 17.Ta(gns�peorkrAdmo.NedgnnentofRecetptof Materials <br /> T�!r'Qf1/4sRrtYP�Najye�Lffgna <br /> mJ/s <br /> Transporter 2 Pdnted/Typed Name Ig Da Year <br /> I naNre <br /> Y <br /> C <br /> F- <br /> 18.Discrepanq <br /> Its.Discrepancy Inftfion Space ❑ Cuanty ❑Type ❑Resitlue ❑Partial Rejedlon ❑FWIRejecton <br /> Manifest Reference Number. ' <br /> 1St.Atemate Facility(or Generator) U.S.FPAID Number <br /> J <br /> V <br /> Ferl� s Phone: <br /> 18c.51gnahae ofAllemate Facility(or Cenerala) <br /> Month Day Year <br /> Q <br /> Z <br /> 79.Hazerdas Waste Report tdanapmenl Method Caries(.e.,codes for hamrdersvraste treahnentdisposal,and recycling systems) <br /> a t H040 2 H040 3. 4. <br /> 20.Dworsted Facility 0rmer Of Cpeator.CeN cnfian of receipt of hamrdous materials mvered by the manifest except as mated in Item tea <br /> Prinsedffyped Name Signature Month Day Year <br /> EPA Form s 00-2 e.3-05 PreWs us editions are bsolete.. ..PP <br /> dean amore Mas a aaproonai°e permits for and will accept the waste the genA§99�%i QUTY TO DESTINATION STATE(IF REQUIRED) <br />