Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1. nee t��r/yD Number G r..Page 10., 3.EmergencyResponse PAho�nel nI I 4 Manifest Tracking Number ['^ �[ <br /> WASTE MANIFEST / ( I\ OQ oZI 4 (�' �� Jv/tel t. .�,.,a ; '.J `e�, JJK <br /> 5.Gpartes Name and Mailing Address Generator's Site Address(9 different than mailing address) <br /> different <br /> C/,4-5S <br /> 2ZZZ S SPI1CLA 1�U StaGV-77jN C.4 <br /> Generators Phone: t,Oq� 77q, <br /> 3� <br /> 6,Transporter 1 Company Nam A ID Number <br /> US <br /> '4 �P SON U S <br /> V� I R O( D /9 <br /> 7,Transporter 2 Company Name I/ (/ Iv U.S..EPAIDNumbers L <br /> 8,Dastgnr FacilityjJOGOand Site AddressN -D,4 <br /> U.S.EPA ID Number <br /> MVvy RSf 11 M6 <br /> 1Y�5 5 , Qor y r /J APA <br /> Facility's Phone: vD n — -Z:3q -3Lo f DO <br /> gra 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(W any)) No. Type Quantity WWoI. <br /> of 1. N P- :3 LVAsI-F, 1 5`1p pm 12I i <br /> 1511) D, <br /> N , o.s'1 � , fah Cly —( <br /> W 2 R 6 <br /> 8. E <br /> MA02t7- - - -- <br /> 4. mmot Ii kL HE?OTH <br /> PE IT/SE <br /> I <br /> i <br /> .. 14.Special Handling Instructionsnor d AddNonal Information 1D / <br /> � <br /> P gicri f 0-1 2�- 5' 3- 1 U <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: Ihereby 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 certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(dl am a small quantity,generator)is We. <br /> Generators/Offerors Printed/Typed Name Signature - - - Month Day Year <br /> 16.International Shipments ' �' <br /> r El Import to U.S. -' ❑Export from U.S. Pad ofentry/exit: <br /> Transporter signature(for exports only): .�'�' Date leaving U.S.: <br /> 17.TransporterAGurowledgment of Receipt of Materials <br /> Transporter 1 Pnnted(ryped Name Signature Month Day Year. <br /> a <br /> z Transpoder 2 Printed(Typed Name Signature Month Day Year <br /> 6 <br /> K <br /> r <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Famous ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Faci iVs Phone: <br /> Me 1Be.Signature of Alternate Facility(or Generator) Month Day Year <br /> 6 <br /> Z <br /> H19.Hazallous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Cerfiricafion of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedltyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />