Laserfiche WebLink
r <br /> Please pont or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No 2050-DO39 <br /> 1 Generator ID Number 2 Page 1 of 3 Emergency UNIFORM HAZARDOUS ag Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 13 q 5-1 002260808 FLE <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> L g r., .,o..r.,�,.��if <br /> q Il S. l�s)!i�.✓c t!9�ai,b e- `p.n.n I-e.", I tip.., <br /> ae-k CG 521 t�s2 N. c�:sln.-s : f-+ <br /> Generators Phone: -5;2 -060 s E oG k+o.t � �G 4 S�O Z <br /> tiI ransporterl Company Name U.S EPA ID Number <br /> AAIO-,C Z-d G°L� :« `r,a,. 4- fA�e 0000-7 o:5-4 v <br /> 7 Transporter 2 Company Name U S EPA ID Number <br /> 8 Designated Faality Name and Site Address U.S EPA ID Number <br /> vs E��1-9r Nz,�a� T..� <br /> P.o. x 5-7L3 H—)( <br /> 8z1- Aird ?,4;;1673N✓T 330 o000 <br /> Faalily's Phone. — �3 — 4 <br /> ga 9b US DCT Description(mduti ng ProperShipping Name,Hazard Class ID Number. 10 Containers i 1.Total 12.Unit <br /> HM and Packing Group(d any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol <br /> cc <br /> rUJ/1/ A°G4'tr 1�AzaQpo. s f,�iAsr� Lr &vire �4� <br /> z 2 <br /> W <br /> i <br /> 3. <br /> ( <br /> i <br /> 14 Special Handling Instructions and Additional Information <br /> ►) ( &,eU — SO 1 <br /> P2 0 A Jr,Z r Nom..•.4-e Q : e-✓v sl <br /> 15 GENERATOR'SIGFFEROR'S CERTIFICATION: 1 hereby declare that the contents of 7a constgnrnent are fully and accurately described above by the proper shipping name.and are classified.packaged <br /> marked and labeledr'pacarded.and are in ali respects in proper cortd Wn for transport according to appfiCable mterratrona and nation;governmental reguiations If export shipment and i am the Primary <br /> Exporter,I certify that the contents of this consignment conkxm to the leans of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quantity generator)or(b)if I am a small quant;ry generator)is true. <br /> r>erator's' emrs Prnt Name signaturew ATknth y ear <br /> .9/1/hV I Ito I !I& log <br /> 16.Interillbtional Shipments <br /> Z E Import t .S. Export from U.S Port of 4trvlexit <br /> TransWer signature ffor exports oN). Date leaving U.S <br /> W17 Transporter Adoowiedgment of Receipt of Matenas <br /> Trans&ql <br /> 1 Printed, N � +gna In ay Year <br /> 0a <br /> QTransporter Printed Typed Name gntun Month Day ypar <br /> 18.Disaepancy <br /> 18a.Discrepancy Indication Space U f� i!! <br /> quanti y —Type J Residue Partial Rejection Full Rejection <br /> Manifest Reference Number <br /> i 8.Alternate Facility(or Generator; US EPA ID Number <br /> J <br /> a <br /> w <br /> Fa6Ws Plane: <br /> w 18c Signature of A!temate Facility,(or Generator) Month Day Year <br /> Q <br /> Z <br /> US19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment.disposal.and recycling sys!ems) <br /> 0 1 2 3 4 <br /> 20 Designated FacAiy Owner or Operator.Certification of receipt of hazardous materials covered by fie manifest except as rioted n rnon 18. <br /> Prinledliyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />