Laserfiche WebLink
08/15/2013 14:20 2095291Gt ti <br /> B I''YETT WAREHOUSE PAGE 13/1.3 <br /> } r'. Form Approved:OMB No,2050-0039, <br /> ry .er• .. <br /> Please pent or type.(Form designed for use on elite(12-pitch) ? tea•e 1 r,`: a,eq,ercleneJ RrsPGnse Fh�ne 4,h7anifa5i TracKing Number ' <br /> 1 G nerator ID Number I, <br /> uKlr:oJPn iiAZAMOUS � ,�g��' 0 0 Z)113 7•-JJ K <br /> WASTE MANIFEST <br /> - <br /> Generator's Nims and Matling Ad res°a J r`. / Genenato?s Site AddrosS(i NTMI <br /> tn�t n>aJ ng aildre ) <br /> f�/fed `'` <br /> _ <br /> %; y <br /> nrratG�'`,Phone: Vv <br /> Nw7',bar <br /> a.Transporter 1 COMPIty Name <br /> U.S.E.PA ID No be <br /> T.Transporter 2 Company Name' <br /> O.S:FLAB Number <br /> .-,. ....._ _ - .: :. - I:201 <br /> .. Ali•G 2 <br /> 8.Des(gnated Facility Name and sits Addres - f ps <br /> ONM NTA L ' <br /> faclli 's PhGna: r%f i � • <br /> er Shi in Name,Hard Class,ID Numb:r, 10-OrnteinetS 11,Total. 12,Unit 13.Waste,Codes <br /> ga. Bb.U.S.DOT Dascdptiorl(including Prop pP 9 No. Type Qunnitj WtNol• <br /> HM and Padking Group(if any)) r� <br /> �n 'r : <br /> Lu t <br /> z . <br /> 4-Spacial a.. Ing nsbudion.andAdditionallrtormadon <br /> r <br /> Ifi <br /> 15. GENERATOR'SIDFFERDR'S CERTIFICATIDN:I hereby del t that n fortraneo d�r g Z ap�blg I �Onal alld national govemmen ret yborshi fpexport shipment <br /> ip �and I am tthhe Primary d <br /> marked and labeladtplacarded,and are in at respecfil in proper conditin <br /> B(polteG I r,,e lily that the contents Gr tnls GonslgnmeM conform to the terms o9 the atmnnad EP.;Ackno�Iaas oT of C o m gmau quan5ty gene azar)iF true• <br /> I Certify that the wdA minlmlzaton statement identified in 40 CFR 2$227(s)(i;I am a large quant{ g- ) �)( Monttt bay Year <br /> Signature <br /> Generator'sltNferoes PrintedlTypW Name <br /> 1 1fj:Intemstianal5 ipmefttsJ E;, ftm L' Pon of entryl� <br /> ❑import to U.S. Date leaving U.S.: f <br /> Transportar aignaturs(for expos only): - YJ <br /> e' 1T.7ransporterAoknowlatlynlentofReCeiptofMaterals hlont'n ray Year <br /> Signafure %'UI <br /> r% f <br /> TranaporterlPriniedlTypodN %r <br /> ©. r�:'•I'aDay year <br /> - 44onih <br /> Sign -re <br /> Z Transporter 2 Pr nie yped Name <br /> IC <br /> H <br /> 18.Diw=Ps-Y ❑Partial Re edw `ol Rcj=-Mien <br /> l F Residue <br /> 1Aa.Ds°•Crepancy Indication SPaca Q QUe„giY 1�TYv` <br /> ^lani 25t Reiererce Num her <br /> U-S.EPA ID tJumber <br /> 9eb.mlemale Facility(orGenerator) <br /> Month Day Year*,. <br /> tai. Fadlity's Ptmrte: <br /> eft I 1 ac.signature of Altemote Facility(or Generetar) <br /> a <br /> z <br /> 19.Ha ardcus Waste Report Managem¢ot Methal Codes(i.a.,cGd�i feu hazardous vtasia Deaf rte d,lisp.=_a,,an racYCling sY 1 4 <br /> 13+ Year <br /> Month ay <br /> sanded in Item 988 <br /> «0.Dasign3ted Facility ihvner or Opera or.Ctird0Ca6on of re g t of I aZnrloL"matLrials xvared t y Me Signature s f <br /> F dJmadffyped Name. _ <br /> :)ESICi %A 20 FACILITY TO GENERATOR <br /> EPAForm 5700-22(Rev.3-05) Previau5 0 a ions are obsolete. <br />