Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator 10 Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracin g�'N�urn or <br /> WASTE MANIFEST C 3! t3$� "`r • a 196025 �9 7 .,7 <br /> R ° 711 FLE <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> 1 6,S. t:.Wild A*. <br /> !:.fAll, <br /> Generators Phone:;? 'iiPd <br /> 6.Transporter 1 ToEfnpany Name p } U.S.EPA ID Number <br /> 6eT@'t`4 33 < Sts i<fi f!OS <br /> inc, (SVS <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Desinoted Facility Name and Site Address U.S.EPA ID Number <br /> P0 1,11.,elm I31�1y,1*in3 }tZ,f I �' ev i. ��Et�+` ly Bt�s✓i it.p }. .* <br /> Facility's Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WtNd. <br /> Q' 1 { +At1t aYtk1 xfi117f@cci tY32g>tt`. iF:f �iC�.if.tj_. i°�9t '{'1"sr?':`" 'p i 9f'Q 6-1 <br /> f • <br /> UJI <br /> 2 2. <br /> W <br /> ( <br /> 3. <br /> AL Ah <br /> 4. <br /> ENVIRON <br /> 14.Special Handling Instructions and Additional Information MIM <br /> 15. GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately descnbed above by the proper shipping name,and are classified,packaged, <br /> marked and labelediplacarded,and are in all respects in proper condition for transport according to applicable International and national govemmental regulations.If export sldpmenl and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)Cif I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generatorsl0iterors Printed/Typed Name Signature Month Day ear <br /> --r 16.International Shipments <br /> F-- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z <br /> Transporter signature for exportsonl : Date leaving U.S.: <br /> LW 17.TranspoderAcknowledgment of Receipt of Materials <br /> Transporter 1 PrinledlTyped Name Signature Month Day Year <br /> O <br /> 4 <br /> aTransporter 2 Printed/Typed Name Signature Month Day Year <br /> tr <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑Residue ❑Partial Rejection Full Rejection❑ <br /> 1:1 Quantity ❑Type <br /> Manifest Reference Number. <br /> 18b.Alternate Facfity(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> a <br /> "- Facili s Phone: <br /> LU 18c.Signature of Altemate Facility(or Generator) Montt Day Year <br /> Q <br /> z <br /> C) <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycring systems) <br /> Uj 1. 2. <br /> 1 <br /> 20.Designated Facility Owner or Operator:CertificaUon of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />