Laserfiche WebLink
0 0 <br /> Pmass pint or bypo.(Fonn desi9nedtor use on elite 12• lch)typeomlef.) Form Appoydid.OMB Na.2050-0039 <br /> UNIFORMHAZARDOUS 1.Generale lD Nwfter // 2.Pay+,Ia -Isogamy ilospasw Plwnn 1� xMomlesl Tmcdag Number <br /> WASTEMANIFEST �� YJSJ W) �.SG/1U� 015384436 JJK <br /> S.OnnsmlMsNama and A+aiop NMmss �omia qrs Site AddresB lildI seem Uan memmg address) <br /> c� <br /> _s ) r�.JC; Y3if - c. ,.�r aN <br /> GezwrelMai'Mnn'. ("7 <br /> B.Transporter l Company Name � U.S.EPAID Numbs <br /> '/ FA11 Stor.�S �Y v tT 22 <br /> 7.Trempmer 2 CompaM Name 0.8.EPA ID Number <br /> 0.lkslgiialoa Faci;y Hnmoaul SdeAOwasa l�r,n:->�j U.S.EPAID Numbe <br /> �, p(�, y i d - rl 1 1 y <br /> Ii4w �1.� [t at.,CcS s. or 3E�7�/� NC5L1✓�at" T-003 <br /> Pn6ylr',Phnnl: BG10 — Z3ct_ 3c L( 1 0✓T-9>_SOr, I. C. <br /> 9a, 9b.U.S.DOT Description Qndudirg Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.1etal 12.Unit 13.Waste Codas <br /> HM and Packing Gm.p(leny)) No. Type Ouanliry Y"Ol. <br /> Ud <br /> 3. <br /> 4. <br /> i <br /> I <br /> a sp.-sat lamllmg mtrucwnsamrndlliorathrom"Im j o <br /> Mj.)(l CiA,( �Yc� <br /> #57? <br /> 15. GENERATOR'SPOFFFROR'S CERTIFICATION:Iha dectare mal lhewnP.misof Nis comgrumn+arounly and eccoremy described above by lho preµosloping aM- arAaedessKed,peckaged, <br /> marked and laboloc/placamad,and are In all mspoils In proper condition for transport accordkg to applicable bwtmlgmlend national 90mmmomai nglalalioms.d exponshlpmsm arid am the Primary <br /> Expofler,I redly that the contends of this rmdgnmmt conform to the terms of the attached EPAAckno l9dgmom of Consent <br /> Iwaiy that The waste mldmbodion stelemanl ldandfmd In 00 CFR 262.21(B)(If I am a large quamily manobabal or(bL&LL&Q a small quality Semmes)Is bue. <br /> Generma'slOOeroes Prinledr!ped Name Signa!e (Mn81 Day year <br /> 16.Imarnmknal Shl <br /> � ❑Imponw U.O. _,1Expotl from U.S. Pod dentryleslf <br /> z Transponord9nalum kor capons omy9: leadrg U.SI <br /> 17.Transporter Acknowledgment of Receipt of Matetines <br /> � 11a,spblurl IuMy}sAl Name , b'i9Pnlee A1aJh Day Yen! <br /> eo Lr <br /> GTransporter 2 Pnnwdrrypad Name Signawre Month Day - Year <br /> K <br /> 4 10.Discrepancy t� ,1 <br /> 10a.Discrepancy Indication Space El op.mity C a� F�s10Re !— Partial Rejection t-JFun Rejection <br /> �I A4:NfcaslVRtoykraba Ncrnhor. <br /> 18b.Allemata FazNty{e Gun+ilaWt) s..y ,1 U,S.EPA 111 Nm0e1 <br /> U <br /> LL Pa�lllyS Phane: <br /> w 18c.Signaluroef Alternate FecdRy,(w Ganeramd ENVIFRONVENFIAL H!E^,LTH Month Day Year <br /> v;=rrgl7iUF�r,.�s <br /> 9 19.Hazamoua Wattle Report Aleregemenl Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycing systems) <br /> rNsa 1 2. 3 4. <br /> 1 20 rkvLcr!n fx•9ny0rttaraUl mato Cen!fuWn recelvlof hazardous materials covered by the maniww l qi as rated in!are 180 <br /> Prnterry"1yl sg�swt k(mm, Day vwr <br /> 11� uJl� �--- <br /> EPA Farm 8700.221 Ov,;t 05) Previous edilions are Obsolete. Ili 3jOfL47 ED FACILITY TO DES FRI)ATION STATE(IF REQUIRED) <br /> + <br />