Laserfiche WebLink
/ass print or type. (Form designed for use on elite (12-nitrtnewrlfar 1 <br />• <br />' <br />-- - - - run mpprovea. UMa No. 2050-0039 <br />UNIFORM HAZARDOUS 1. Generator ID Number 2. Page l of 3. Emergency Response Phone 4. Manifest Tracking Number <br />WASTE MANIFEST Cat Z�Gv3�i r NU8- 7,g _W" 009479250 JJ K <br />5. Generator's Name and Mailing Address S, Generator's SlteAddress (ff different than mailing address) <br />ZZZZ �S -5/Aja--, lti2 AUG <br />Sri V- 72W CA 5P6 2,1S <br />Generator's Phone: ' <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />4FGS �L=iia!>nll�� LLC �,a'D[�03 96 3 Z <br />7, Transporter 2 Company Name U.S. EPAIO Number _.. <br />8. Designated Faclliy Name and She Address CLEAR! I}AO-864.S> LL -r' U.S. EPA IO Number <br />p2j , <br />_4c2t2y��SA <br />Fac7ity's Phone: .52d� CA <br />ga. <br />HM <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />and Packing Group Qf any)) <br />10. Corel am <br />11. Total <br />12. Unit <br />No. <br />Type <br />Quantity <br />WtNol. <br />13. Waste Codes <br />NQ 30 Nae 7;d>21 tiS i >Asr�$I <br />SoLtD >t�.D•S. L/-011 PAXa l9J P46/ 11 t� pry 5-35/ Q <br />W <br />")( <br />OS� I <br />2. NA 30 7-7 !fA ?►4e.DOtJS A,_5 a4S I <br />� <br />spL �� .x/.06 • ��� ��sa./s), 9� Py�l l .��+'� r S 2 •P <br />4. <br />•" <br />14. Spedal Handling lnsWctlons end Additional In on <br />Pr�O F/L.l7� Ate t+, --X3 5/9 y=r"'i' !' L/ <br />15. GENERATOR'SIOFFEROR'SCERTIFICATIONI 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 Iabeledlplacarded, 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 EFAAcknowiedgmentof Consent. <br />I codify that the waste minlmizatlon statement Mentifed In 40 CFR 262.27(a) (If I am a large quantity generator) or (b) (If l am a small quantity generator) Is We. <br />Generator'slOferor's P' tedIT ad Name Signature Month Day Year <br />A w I -A P10 .s- z z tZ, <br />J <br />Z <br />16. International Shipments <br />El Import to U.S. ❑Exportfrom U.S Port <br />- <br />ofentryledt <br />Transporter signature (for exports only): Date leaving U.S.: <br />w <br />17.TranspodarAcknowledgmenlof Receipt of Materials <br />. <br />Trenspumr 1 rnmedrlyped Name Signature Month Day .Year <br />CTranspolar <br />2 Prtnted?yped Name re - <br />Month Day Year <br />H <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑T e <br />YP ❑Residue ❑Partial Rejection ❑Full Refection <br />Mangest Reference <br />18b. Niemela Facility (or GeneraleNumber.) <br />J <br />U.S.EPAID Number <br />5 <br />LL <br />Fadlit/s Phone: <br />w <br />18c. Signature of Alternate Facility(or Generator) <br />Q <br />Month DayYear <br />to <br />to <br />19. Hazardous Waste Report Management Method Codes #.a., codes for hazardous waste treatment, disposal, and recycling systems) <br />1 <br />2. 3. <br />4. <br />20. Designated Faality Owneror Operator. Certificetion of receipt of hazardous materials covered by the manifest except as noted th Item 18a <br />Prime Irlyped Name Signature '.y t Month Day Year <br />EPA <br />Form 8700.22 (Rev 3-05) Previous editions b I t <br />areo soee. DESIGNATED FACILITY TO DESTINATION- STATE (IF REQUIRED)_ <br />