Laserfiche WebLink
From: 08/0010 19:41 #453 P.002/002 <br /> Please print or type.(Form deTgmed for use on elite(12-phch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS t.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C.Aa,I at Aug 1p RI tt.7 r' 1442 7 G B F <br /> S.Generator's Name and Marling Address Generatofs Sile Address(gdiflerant than mailing address) <br /> Wlt,W F-PULY VSNE Ce?RAF'ANx' <br /> 17M VEA N COLD <br /> T FBM Y,i':d 06177 <br /> Genarabfs Phone p - a e (9 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> SfiCB'HA?o5,r?F:373 5t.'H IIT1CiFX ,I1Jf C.Alk?DnC46d97 <br /> 7.Transporter 2 Company Name U.S.EPq ID Number <br /> 8.Designated Facility Name and Site Address CSFB+R RAW4-110 COFA(3VA,Ilk U.S.EPA IO Number <br /> 118"WIiI E R0Lfi:RD �:P+,E?ft[i±1!)If3Sit1 <br /> RANCHO Ct RLW. A.CA S161 42 <br /> Facili sPhone:(sts,3151-M <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name.Hazard Class,ID Number, 10.Containers 11.Total 12 Unit <br /> HM and Pad6ng Group(if any)) No. Type Quantity WLNd. 13.Waste Codes <br /> t. t;t, Ab "F`Ft1HSIPIi:IFBGKE1.Riftr +T'E'f13AS...'s,lIFJ3`14f}.p i F}Nf �h£ tv<; F}(}pt FQC {C1D35 <br /> o t[:filllF 6Ctp ft <br /> zip._. .. <br /> z 2. a' ,Vtrr�t'iF. !4r"l!?'c:z4aeGr�WTNE�iINMkS .FFeKlLgtEUN2TlCLf;C,. t F}F P t7FI!'lA ', i37 <br /> 3. <br /> i <br /> 4 <br /> 1, <br /> /4.Special Handling In"lons and Addigonal information <br /> �nf1 F�aTvrl[.r.+�Fz7�lsatl,PF�aal7rar,(r�:�stc;t�eac� - �'s�l <br /> D02-PftIR E6,MERC1IRY cow AJI*43FFtEFah9r)r�TF:l2> <br /> APPR0134ATF. PROTIECTIVE CLOTHING <br /> 15. GENERATOR'S IOFFEROR'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.paaaged. <br /> marked and abeledlNacarded and are in all respects in proper coral for hishapon according a applicable international and national governmental regulations.If export shipment and 1 am The Primary <br /> Exporter,I codify that the contents of This consignment conform to the ams of he attached EPAAcknavledgmenl of Consent. <br /> I certify that the waste minimiz88o11 statement idenMad in 40 CFR 262,27(s)if I am a large quantity generator)or(b)(HI am a small quantity generator)is true <br /> Gene�mb/i'�s/OB�erofs PrintedfTyped Name Signature Monih Day Year <br /> 16,International Shipments ❑Impart to U.S. ❑Export from U.S. Port of entry/exit: <br /> ZDate leaving U.S.: <br /> — Transporter signature(fo(exporis oNy): <br /> W /7.Transporter AdmoMedgmenlof Receipt of Materiels <br /> Transporter 1 Pdnled/Typed Name, Signature _ Month Day Year <br /> E�„ �. .= e) <br /> rn signs Month Day Year <br /> Z <br /> Tramp eron2 nnled?Yped N me <br /> K <br /> H <br /> } 18.Discrepancy <br /> I8a.Discrepancy Ind'ration Space Quantity ❑Type ❑Reudue Op. ad Rejection ❑Full Rejadion <br /> Manifest Reference Number. <br /> tab.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> LL FacA '5 Phone: <br /> w leu Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> N19,Hazardous Walla Report Management Method Codes(i.e.,codes for hazardous waste treatment.disposal,and recycling systems) <br /> i 4 <br /> Ii <br /> 20.Designated Facility owner or Operator Certification of receipt of hazardous materials covered by the maNiast except as noted in Item 18a <br /> PriMe yped Name, r Signature } sMonth Day Year <br /> LLLL <br /> EPA Form 8700-22(Rev.3-05) Pill editions are obsolete. <br /> DESIGNATED FACILFrrS copy <br />