Laserfiche WebLink
Please Print or type.(Form designed for use on elite(12-pitch)IypewriterJ �' ry' �<• '{I' Form Approved.ME No.2050-0039 <br /> 1 Generator ID Number 2 Pegs 1 of 3 Emergency Response Phone 4 M nIt tT osk�'n u 4e <br /> UNIFORM HAZARDOUS -:;�,L>uG)vSr"i�i Z 1 d�ch. - '7�r� �1� 7D J 04 FLE <br /> WASTE MANIFEST 0'-'�'� <br /> 5.Genestors Nam and Milling Address Gamature Site Address Iff different than mailing address) <br /> 7-Mavatl Irr. F!ay ;: 4;917 <br /> t), Bur 31'Mi 27275 f;C71Si+1T;A`f CLUoi &<' <br /> =' wo' antaMal'rq.Of'ita, C'Sa. ale s ,Mi34 7-, C:it STCC :TL4 i.,4 �w:21xf <br /> Gao retols Phone: - <br /> 6 Transported Company Name US EPA ID Number <br /> EL t;n4MG <br /> 7 Tmnsporter2Compeny Name US.EPAID11Num'bye^r JJ p ,✓ <br /> 3 it e h `.u r t t ("' "I / � Q tJI Y3 1 's <br /> .Designated FacilyRy Name and Sale Mdrdss US EPA ID Number <br /> -}oMef-iv-I�.4".fwl�bil <br /> c7:aT01z_I0:V52 <br /> Facility's 15how 3 <br /> 9a <br /> 9b US DOT Description(Including Proper Shipping Name Hazard Class IDNumber 10.Contlinem 11 Total 12 Unit <br /> HM and Packing Group(if any)) PpNO. Type Ouanety `MNlLo13 Waste Codes <br /> K 1 t asie COf T:i ,i 1.JQLI.d cd.{C Irhoi-e+dl !1.O 5., <br /> u�7 N�I•JJ I . <br /> W 2 S BEEN OUALIFIED <br /> FOR RECYCLING/TREAI ENT AT THE <br /> :lN Eal ilyrpt <br /> 3 CALIFORNIA THIS FACILITY WAS IWE NECESSAR _ <br /> PERMITS TO RECEIVE YOUR WASTE STREAM AS ______ <br /> 74 Special Handling lnswctiasand Additlonal lrrformetlon - (( .ALl. �^v:30f�i`{lYYfl.t�'+ 2�a" <br /> / X <br /> 15 GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contends of this consignment are fully and accuralety,described above by the proper shipping name,and are classified,packaged <br /> marked and Iabeleclumarded,and am in all respects in proper written to,transport according to applicable international and national governmental regulations If export shipmentand I em the Primary <br /> Exporter,I one"than the contents of this consignment conform to the terms atthe attached EPAAcknowledgmed of Consent <br /> ImT%that the waste minimoaton statement Identified In 40 CFR 26227(a)(if l am a largequanlity gmemllor(b)(If l am e Ih ntity generallis we. <br /> neratorsrORorors FrIntelfTyped Name �9ne re r. a ay Year <br /> j..3i r`,' ti'la3rkhafE 0?^C i Oe1 ,hi4.!9.D(c O!y?ftEf`:1LBf �-�-,�,_._.. ] x+ <br /> J 161ntemetionel Shipments s <br /> blog <br /> L ❑Impart to US El Export from US Pon ofentrylexit: <br /> Z Transporter signature for Mods and : Date learl U.S.: <br /> W 17.TmnsporterArknmvledgmentd Remiptof Materials <br /> irensponer I PV(rVTyped Name/ Signature / Merril Day Year <br /> an CA <br /> Q Transporter,.PrhitedRypetl Name f / ignatul.—) Y_ month Day YWF <br /> `! <br /> 18.Discrepancy <br /> tear Discrepancy Indiction Space ❑ Dial ❑Type ❑Residue ❑Pertml Rejection ❑Full Rejection <br /> Manilas[Reference Number <br /> 181a Alternate Facility(or Generator) t LA 1 J, US EPA ID Number <br /> J_ <br /> LL <br /> Facility s Phone: <br /> t-1 02 <br /> w 18c Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> y19.Hazardous Weals Report ManagemenlMelhod Cedes Cie..codes for hazardous waste treatment,disposal and recycling systems) ' <br /> 0 1 2 3 4 <br /> s1 <br /> Y20.Designated Facility Owna a Operator.CerUficabot of receipt of rdous materials covered by the martian except as noted in Item 14-; . <br /> Pdr;edrryped Name y 9grmNre r / 1 Month Day Year <br /> EPA Form 8700-22(Rev 3-06) Previous editions are obsolete ' ,�. DESIGNATED FACII ITYTO GENERATOR <br />