Laserfiche WebLink
«R"'3 "moip'iy,r wi3�n80days•• <br />'leasee p - e. trorm esigne or use n li a (2-putc pewnter. 4W br a Co. X12 0 Form Aooroved. OMB No. 205D-OD39 <br />UNIFORM HAZARDOUS 1 1. GG%/L enerator ID Number <br />`'• <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Trackin Number <br />004415217 <br />WASTE MANIFEST (/ /i,', 1: ! <br />1 <br />1-60a44,A'�10 <br />JJK <br />Generators Name and Mailing Address ,- •, r J, L Generatoes Site Address (if different than mailing address) <br />Generator's Phone: <br />6. Transporter Company Name i_y,.::F b!, U.S. EPA ID Number <br />7. Transporter 2 Company Name . EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />{iySa al, If1L. DEC 01 2014 <br />CAUW3O"AS& <br />ENVIRON <br />FaciliNs Phone: 1f;._Jg -mil MEN <br />9a. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, DE <br />it. Total <br />12. Unit <br />13. Waste Codes <br />HM <br />and Packing Group (if any)) <br />No. <br />Type <br />quantity <br />WINol. <br />Z <br />2 <br />CD <br />3. <br />4. <br />14. Special Handling l shuclons and Additi allot a6 n <br />UN amp PIK <br />15, GENERATOR'SIOFFEROR'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 labeledlplacarded, 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 cannily that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement Identified in 40 CFR 262.27(a) (if I am a large quandly generator) or (b) (if I am a small quantity generator) is hue. <br />GeneraloeslOHeroes Ppnted/fyped Name Signatures Month Day Year <br />c=j <br />t-- <br />16. International Shipments j <br />❑ Import to U.S. ❑ Export from U.S.. Pod of entrylexit: _ <br />z <br />Transporter signature (for exports only): i Dale leaving U.S <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />K <br />Transporter Printedfryped Name Signature Month Day Year <br />Q <br />Transporter 2 Printedlfyped Name Signature Month Day Year <br />tr <br />r— <br />.} <br />18. Discrepancy <br />ran. Discrepancy Indication Space ❑ quanti ❑ Residue ❑ PaNal Raection ❑ Full <br />ty Type j Rejection <br />Manifest Reference Number. <br />16b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />i¢ <br />Facilitys Phone: <br />w 18c. Signature ofAtemate Facility(or Generator) Month Day Year <br />Q <br />fI~ 1), Hazardous Waste Report) <br />�lr Ra ort Management Method Codes (��a�� codes for hazardous waste treatment, disposal, and recycling systems) <br />o <br />1. <br />2. 3. - <br />4. <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item lee <br />Printedrpyped Name Signature Month Day Year <br />EPA Form 3700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />