Laserfiche WebLink
�J <br /> Please print or type.(Form designed for use on elite(12-pitch)ty0ec) • Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 e <br /> 'WetrID Numbert 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tacking Number <br /> WASTE MANIFEST {�5 Q -1 6-371-05747 017145357 JJ K <br /> Geneatofs Nam and Maili Address �1 emtot ress dddfereyThan lin address <br /> ^wC�,4 rtiloti?CA q458-3 `Crot��( C.4, q 3 <br /> Generatels <br /> 6.Transporter 1 Company Name, U.S.EPA ID Number <br /> =•;,uti?s t`.M.11Pir1pxaLxetT,v1. sERG90E�C'k:. r.�dgO�dEn3_'Ccly; <br /> 7.Transporter 2 Company Name U.S:ER411!i <br /> I 1 <br /> S.Designated Facility Name and Site Add ,r. U's Y_P!`-'Rxt 1R S-11 IFIL. U.S.EPA ID Number.;;y�j .p-,.� <br /> 161; 9013Tf1 <br /> V FL St S,-CRA7,Ewo,aa: vwt <br /> Facility's Phone: <br /> gra 91a.U.S.DOT Description(indud'og Proper Shipping Name,Hazard Class,ID Number, 10.Conarea 11.Total 12Unit <br /> HM and Packmg Group(dant')) No. Type Quantity WI&U. 13.Wash Codes <br /> 1. NON FfPA z'IA.ZAR&:JS VVI VF WLW 10111..'t Wa fij .. 3 <br /> C !'� <br /> z 2. <br /> w <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> "_11.II <br /> I I4W.11.ERs TO HE TRAUK-0 AND USE APPRCJ'VVA PPE. <br /> f-F. C0l4TrPGTf1Ft FS•Fit3S EW'IPMWl!rdTAL. 3EF, IC:E:s <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment am fully and accum"described shore by the proper stupphg name,and are classified,package4' <br /> marked and labeledlpacarded,and are in all respects in proper condition for transport according to applicable intemationalantl national governmental regulations.If export shipment and I am the Primary <br /> Exporter,1 certify that the contents of this consignment conform to the terms of the attached EPAAcimowledgm nt of VsenL <br /> lAertity that the waste minimization statement identified in 40 CFR 26217(a)(d I aro a large quantity genemt*or ytffl am a small quantity generator)is true. <br /> G cfsl( s//Pdnted/fyped Name / IT <br /> [[ \\ ,Silgr�elVre - Month Day <br /> 16.International Shipments �/ -' <br /> i- ` ❑Importto U.S. ❑ExP from U.S. Patofw*yrexit <br /> = Transporter signature(for exports only): Dab leaving U.S.: <br /> W 17.TanspoderAckno0odgment of Receipt of Materials <br /> �y. Taggportea l Primed/Typed Now SigneNre 7 <br /> _ MoMh Day Yea <br /> ,+ <br /> rn <br /> M <br /> Transporter Z PrtetedRyped Name Signabre Manch Day Year <br /> I <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ �n T Residue <br /> Quantity ❑Type ❑ Partial Re)ation ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> v <br /> LL Faciftys Phone: <br /> uta ft Signature,of Alternate Facility(or Generator) Monty Day Year <br /> R <br /> 2 <br /> y19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2, 3. 4. <br /> 20.Designated Facility Omer a Operator:Cedifickion of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pintedflyped Name Signature Monty Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />