|
DEC-15-201510:45 From: To:12094683433 Page:2/4
<br /> •Please print or,lypa.(Kota)dost nod for use on elite(12•pitch)typewriter,) Form Approved.OMB No.2050-0039
<br /> UNIFORM I-ImRims 1,Generator lD Number2.Page i of 3.Emergency Response Phone. 4.Manifest hacking Number
<br /> WASTE MANIFEST C aA L 0 0 0 � 9 a 6 7 8W 4?4w92 )Q-nalzm. 009916415 JJ K
<br /> 5,Generator's Name and Meiling Address Generators site ss(if different then mailing address) ..
<br /> P6iO4GU /HAUTORET0,11i
<br /> 255,4,10 MT KV
<br /> Gcncralors Phondt 2 lib 9 ? 9 !•t 9 Pi 0
<br /> 8,Transporter I Company Name U.S.EPA ID Number
<br /> s=L��.:e�4:�1tjA'ENVII=�fJi`,3ltf'at�:3>}� .fie RVICE', 'N(.,".' C, A R 0 0 t) 1 Y 1 0 1 7
<br /> 7,Transporter 2 Company Name U.&EPA ID Number
<br /> W)Is;,C:71t`tiflf'E RECIC'iWRY S;'j:iTEM WC G A 'R 0 0 is 1 1 5 it =`
<br /> a.Designated Fadllry Name and SHe Address " U.S_EPA ID Number
<br /> f
<br /> Y l�rfA YS;,3 LL
<br /> ..YUNIA AS
<br /> Fadllp�s Plane €):ix; s°-:K:Z A Z R 0 0 GI 5 1 5 9
<br /> ga, gb.U.S.DCT Description(hicluding,Proper Shipping Name,Hazard Class,ID Number, 10;Containers N.Total . 12.Unit 13.Warta Codas
<br /> HM and Packing Group(eany)) No, Type Quantity WLNoI.
<br /> a 1 I,i li1l•i '�l?, utf�a�t L.801 i4:;<S(BRAKE SKRVINc:.yti)
<br /> W2.
<br /> tsVtLj
<br /> 3 ,.
<br /> DEC 16 201=1
<br /> 4.
<br /> 14:Special HandtingInstructions andAddilionallydohnn6ort !TE's -{;c'lSiiP;yfli J(i;f} 4(dC?rl6'I7'I ter
<br /> OJ
<br /> (lAi�+t�D.s"Pr;f:;t FIV4(9.1P'CltAiur Ir k.40131aE;'rn. .S;vat(i.',.cth R1', 07
<br /> 15• GENEftATOWWOFFEROR S CERTIFICATION:I hereby dectare that the contents of this consignment are fullyand accurately descnbed above by the proper shipping name,and arc classified,packaged,
<br /> marKO and labelo4lacarded,and are In all respects in proper condition for VanspOn aCcofft to applicable internal4A and national goyemmcnlal rogufab".If expml shipment and I am the Primary
<br /> Cxporler;I certify that the contents of this consgnmcntcon(omr to the terms of the attached EPAAcknowledgment of Consent. '
<br /> 1 certify that the waste minimization SWICInent Identified In 40 CFR 26227(a)(if I am n In*quanllty Onerator)or(b)(it(am a small quantity generatoij is bua.
<br /> G.ggflcratorsl0fferor3 PdniedRYPed Name y �igt>atufe 7 t�onih Day Yoar,
<br /> V.
<br /> r t 16,International Shipments
<br /> ❑fmpoKto U.S, ❑Export from U.S. `'Pon of enuylexh:
<br /> Transportor signature(roc exerts only): r`,r Dale leaving U.S.,
<br /> W 17.Trertsporle(AckncwledgrnenlofRecelptofMaterials
<br /> G 'I'rmispaler'll Kntedffy ed Name (t ' Signs ri Month �Day Year
<br /> z Transporter?,PdnWVped Names 1 _ r 3lgnature Month Day Year
<br /> r-
<br /> ,
<br /> 18,Dfscrepsitcy
<br /> lea.DistrepawCy Indleatlon Space ❑ Quantity 01ypc ❑Residue ❑ParrrW Rcjudion ❑Full Rei db.
<br /> Manifest Reference Number.
<br /> tab.Ahcrnate Faoliky(orGanerator) U,3,PPA In Number
<br /> LL FadttysPhone:
<br /> Ow leo,SignatureofAitemeteFacility(or Generator) Month Day Year
<br /> d
<br /> rz
<br /> 19,Hszardogs Waste Repot Idanagemant Medlod Cortes(Le.,codes forhazardous waste treatment,disposal,and recycling systems),
<br /> 0 1, 2. 3. 4.
<br /> 20.Designated Facility OWnor or Operator.Ceffl allon of receipt of hazardous materials covered by the manifest exc*as noted In Item 18a
<br /> Printed(Typed Name Signalure Month Day Year' -
<br /> EPA Form 8700-22(Rev,"5) Previous adl(lons are obsoleto. GENERATOR'S INITIAL C()PY J
<br />
|