Laserfiche WebLink
Please print or type.(Form designed for use on elite 02-pitch)typewriter.) Form Approved.OMB No,2050a39 <br /> UNIFORM HAZARDOUS <br /> i-Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4.ManifesTrackingTracg Number <br /> 1n, I I q� J'02 36 <br /> WASTE MANIFEST -At�$X,3 �e, I !] ---- 1 3332 GBF <br /> 5 Generators Generator's Site Address(if different than matting address) <br /> -.41(s Name and Mailing Ad <br /> J 411 <br /> Generator's Phone. U.5.EPA ID Number <br /> 6,Transporter I Company Name <br /> 7 Transporter 2Company Name U S.EPA M Number <br /> 8.Designated Facility Name and Site Address U.S EPA 10 Number <br /> EN W 1,N .A4MkN4& M69 I Nk V <br /> .!I <br /> FacflitysPhore: <br /> 9, ;b U S.DOT Description(indiding Proper'.hipping Name,hazard Class.ID Number. 10 Conta-'riers 11 Total 12.unit 13 Waste("Odes <br /> HM and PadOg Group(if any)) Na Type Quantity Wt P/01. <br /> i P4 tll l.lJiF „k 14 <br /> W 1( t V-1P,'V77 it� 'AM 141!If::WA17�1 I i!) 14 P <br /> 0 <br /> Rf-I'll-14F C1,A,""I i?4r,4Y)19' <br /> / <br /> 2. <br /> LU <br /> 0 RECEIVE <br /> 3. mAi-,� 17 2014 <br /> 4. <br /> ENVIROW E 14 1 OR L <br /> HEALTH DEPARTNIEWY <br /> 14.Special Handling Instructions and Additional Information <br /> t-k,.aW it,lIA'44.,/'a I Wilt, -,f.L)I ',,I-I, OLA01P F I i 11 <br /> i vw;f I lVt:(It.i, <br /> 1,4w,R-,,,I t 4"1 (14'AJ <br /> lo. GENERATORVOIFFEROR'S CERTIFICATION: I harety declare that the contests of this connnriert are fully and accurately described above by the proper shipping name,and are Classified,packaged. <br /> marked and labelediple.ardec,and aie in a,1 respects in proper condition for transport according to applicable intarrational and national governtriental regulations-If export sholient and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform*.o the terms of the attached EPA Acknowledgment of Consent <br /> I carti.fy,that the waste minimization statement identigied in 40 CFR 262,27(a)(if I,am a large quantity generator)or(b)(HI am a small quantity generator)is true. <br /> Generatoes/Offerces Printed/Typed Name Signature Monti- Day Year <br /> -j 16. nternati;nai SnipmentsPort of entryttexit. <br /> E;Impon:o U.S ❑Export from L,5 <br /> Tr@isooter siqpat;,ire tfor exports only) Date leavirgU.S.: <br /> W 17 Transporter AanovAedgmerit of Ref:Ript offOaterials <br /> ransTranspoer I Printecirlyped Name .r' Signature Month Day Year <br /> no l <br /> W &gnaw Mon Day Year <br /> Z Twi�cfrter 2 Print Typed Name <br /> W- <br /> 18 Discrepancy <br /> 18a.Discrepancy indication Space ❑ Quantity ❑ OReSidut 7 Partial Rejection Dull Rejection <br /> Manifest Referemie Number. <br /> 18t,Alternate Facility(or Generator) U.S.EPA 10 Number <br /> u- Facility's Phone: th Day Year <br /> 10, <br /> 8c Signature of Alternate Facility lot Gererator) <br /> q Hazarcous'Naste Report Management Metriod Codes 6.e-codes for hazardous waste tieatmerl,di6pCl3al.and recycling sYstemsi <br /> 4. <br /> 0 T- 7 <br /> 20 Designated Facility Owner of Operator.Ceniftcation of receipt of hazardous materials covered by the wrtifest except as noted it stem 18a Notice: State of California requires <br /> Printedayped Name I Signature gernerator to photocopy and mail to <br /> EPA Form 8700-22(Rev,3-05) Previous elitions are obsolete. DT5C with 30 days: <br /> P-0 BOX 400 <br />