Laserfiche WebLink
05/23/2011 HON 15: 56 FAX 209 467 1126 Blackmun Equipment ®014/029 <br /> Please print a type.(Form designed forum on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0099 <br /> UNIFORM HAZARDOUS 1.Ceneraar l0 Numbcr 2.Pagt 1 or 3.Emergenq Reepanse Dhone a.NmNeat 7reddng Numbor <br /> .WASTEMANIFEST '1•�i,N;-r'„)IryyW h) Q JJK <br /> 3.Generator's Name and MaTrigAddnass Generators S leAddreaf(If dmfemnl man meting address) <br /> j Generators Phone; ! <br /> i6,Transporter l Company Name uS.EPA ID Number <br /> 7.Tfawporler2 Compa y Name U.S.EPAID Number <br /> 11.10mignated Fadity Name and SlIeAddRe® US.FPA ID Number <br /> i ;�...,..�... �.rr.,,•ww]eCL�1 Nh�•VtJwYJU�t QST C: <br /> � FaciiI's Phoma: <br /> 9s. 9b,U.S.DOT Description(including PmperShkVng Name,Hazam Cess,IDNumbr, 1D.Contta 11.Tow 12.Unit <br /> ! HM and PaCMn9 GrauD(Nally)) Nm. Type Ousnbty NAN01. 13.Waste Codes <br /> I 3' <br /> 1 Hwdkq haInuellons antlAddlliwal lnitmmtlon <br /> t 15. GFNFAAMMSlOFFEROR'SCERI]MAMON: I hereby dedam that to oonto*of reit wnsgmmnt"fully and aocuroldy de5rhad above bylhe proper ahryphg name,and are classified,packaged, <br /> marked and lebeledlplecarded,and are n all respect in pmperwnd6nn formarapor a r=ing la appG®ble mismeaonetand national gowmnantal regulators.It export aNjimeil and l3rift Primary 1 <br /> i fxponer,IcMfythat NecantsnleofthlgwnaVmmiotdmmloftMm;oofdiedWd*EPAAcknvAcdgmmtuf Goraent <br /> I cerllfylhat t e waste Mrtmba5w sbremenl ideri66ed In 40 CFR26227(a)(dl em a large quen6ry generator)or(D)(if]am a smd quentitygerxretor)Is mue. I <br /> Generatory03erprs Pertedllyped Noma Signature Month Day Year <br /> 1 _ I <br /> -r 16.Inlmidonal shipments <br /> r F ❑Imponro Ua"". ❑Expan from U.S. PoRdmbylaub <br /> TrercperterdOrmum(rnr expang w y); Dabs lmMlq US, <br /> lI W 17.TranspowAckmlleloment ofRerapl of Materials i <br /> ! a Tmnspomx l PdnteNTyped Name Slgnaluro Mmth Day Year <br /> a , ..� !: %: ter,...—.-_....,f /f .:,n,.�.. •- r',,: <br /> RTmnsp542Pnnled(Typed Namo 5"ryysahse Month Day Year <br /> r- <br /> .s. ia.Dltaepmcy . <br /> 183.Discrepancy Indication Spare ❑ mmdly ❑Type <br /> ❑Reskue ❑Penia ReJectnn El Full Rejeclon <br /> I <br /> ! Mma7eal Resonate N <br /> 1gb.Allemete Feollb for Generator) US.EPA ID Number <br /> V <br /> FaoSty's Phone: <br /> aw 16p.SigmWm DfXtem3le Fadlty(or Gmeiamr) Monm Day Year <br /> Z <br /> H19.Hazardous Waste Report Management Method Codes(ie.,wdes for oafamaus waste treatment,di3posal,and recycling systems) <br /> G 1. 2 3. 4. <br /> 20.Desigoad Fadllfy Oveefm Operator.Cerfdcadon of receipt of hazardous matanals covered by the manilesl except as ndtd n Item 180 j <br /> Pritad/Typed Name SigneWre Mom Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous edl0ons are obsolete. GENERATOR'S INITIAL COPY <br />