Laserfiche WebLink
Please print or type.(Form designed for use on site(12-pitch)typewriter.) �lc��! �P�, �}r� - Fan Approved.OMB No.2050-0039 <br /> UNIFORM HAZIRUOUS 1,Genenabr 10 Number 7 Page 1 of 3.Emergency Response Phone 4.Manihst Tacking Number <br /> r WASTE MANIFEST C b �to) s-4 - ?�+''J 0 033 815 9 8 11 <br /> 5.Generators Name and Mailmg Address Generators Site Address if d1 erant tan malting address) <br /> Generators Pho e���4�J C� �Jlz�d <br /> B.7renspoter 1 Company Name U.S.EPA ID Number <br /> 2-1 IY re-4 �_�^� r��a 1 6--� a ( Z <br /> r 7.Transporar2 Company Name U.S.EPA ID Number <br /> SLr P <br /> 8.Designated Facility Name and one ALdress _ U.S.EPA ID Number <br /> Facill s Phone: L/ O <br /> 9a 9b.U.S.DOT Description(mduding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Und 13.Waste Codes ) <br /> HM and Packing Group Cifany)) No. Type Quantity WYNoI. <br /> I <br /> 1. <br /> K . l ( " ( b ) <br /> 0 <br /> a <br /> r s <br /> Z 2 <br /> W <br /> r 3 <br /> 4. 1� <br /> I <br /> 1 14.Spscial Handling Instu0ons and Additional Infoimaton ) <br /> II <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the cements of this consignment are fully and accumtaly desMbad above byline propershippingnams,and are Gasified,packaged, <br /> marked and labeledrplacarded,and are in all respects in propercondntm fa transport according to applicable International and national governmental regulations.H wportshipment and I am the Primary i <br /> Exporter,I cedify that to contents of this consignment conform to to terms of the attached EPAAdmowledgment of Consent. 1 <br /> I cerdhytat to waste minimization statement identified in 40 CFR 26227(e)(llama large quantdygerwaator)mid)(Iam a sma11 quantity generator)is We. <br /> - <br /> Genaator5lO8erWS PrintedlTYPetl.NamSigmeame Month Day Yeer <br /> e IO <br /> I p 0 <br /> T mere <br /> r 16.Intemadorel Shipments ❑Import ta U.S. ❑Export hr,U.S. Pod oferdrylett <br /> z Transporter signature(for exports only): - Date leaving U.S.: <br /> C 11.Transporter Acknowledgment of Receipt of Materials <br /> LJ <br /> r Transporter 1 FrintedTyped Name Sow Month Day Year <br /> a <br /> U �� / — <br /> z Transporter 2 Printed? Name Signe Month Day Year <br /> /2- <br /> 18 <br /> L18.D¢aepancy <br /> 18a.Discrepancy Indication Space �, ❑ 1 ❑FWI Re 1 <br /> ❑ Quan ❑Type <br /> Residue Partial Re ectim lection <br /> r <br /> tib.Alternate Facility for Generator) <br /> Manifest Reference Number. , <br /> U.S.EPA ID Number <br /> � i <br /> zi <br /> U r <br /> r LL Fadity's Phone: <br /> Maj 18c.SlgnstureofAtemate Facility(or Generator) Moth Day Year <br /> a <br /> a <br /> r y 19.Hazardous Waste Report Management Metod Codes(i.e..codes for hazerdouswaste bestrem,disposal,and recycling systems) <br /> W t. 2. <br /> 20.Designetad Facility tamer or Operator Certihcetlon of receipt of hazardous materials covered by the mandest except as noted in Item 18a <br /> r Printecirryped Name Sigrahure Mont D , Year <br /> b¢ ryI <br /> EPA Form 6700-22(Rev.3-05) Previous edi8onsare obsolete. DESIGNATED F LITYTODESTINATIONSTATE(IFREQUIRED) <br /> r <br />