Laserfiche WebLink
Please pant or type.(Form designed for use on elite(12-pAch)typewriter.) r ` ,xUnc Farm Approved.OMB No.2050-0099 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Par gn 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFESTt ,�,.:+ '1 Tr'.4lyv';�' .73 6 48 JJK <br /> 5 Generators Now and Making9dctrgsG l iiaretors SlteAddress in dJks&&nt than niallung address) <br /> - i;.°ti a�,� tVr.T s'S:» Wt iatYv.i'1vY: ' •�( `� <br /> l Jfa r <br /> kvr.fv.. =�.• <br /> Gererators Phone: Y,V'kr �✓y- "`t;t"� C " ' �.; Tl�t�)11 (u F `N t °41 <br /> h <br /> E.-'ansporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name US.EPA ID Number <br /> 8.Designated Facility Name and She Address U.S.EPA 10 Number <br /> Facility's Phone:' <br /> - 95.U_5-DDT Dasmiptiom(including Pmper-ShiplagName,Hazard Class,ID Number, 10.Containers 71.Trial 14,Unit. <br /> Hbt and=m(ldrg Group bf any)) No. Type Quandly. WWoI. 13 WasteOodes <br /> i <br /> rX <br /> K <br /> W <br /> OP <br /> 3. <br /> 4. <br /> 14.Special Handling lmunctons andAdd'nioral Irani 1 <br /> t . <br /> L. <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the come s;of this consignment are fully and accurately described above by the proper shipping new.and are small packaged, <br /> marked and Ialealedlpcarded and are in all respects in proper condition for transport according to applicable intemalonaland nalioral governmental regulations.If eq+od shipment and I am Cee Primary <br /> Exporter,I candy that the contents of this consignment canhermto the terms of the atocAed EPAAckradmedgment of Demand. <br /> I comfy that Ce xesle mlrimizaaon slatementitlentlfied dh 40 CFR 262.27(a)(If I am a large quandtygenereor)or(b)lit I am a small quantity gerremto)Is Cue. <br /> GeneratorsiORerors'rimed'qpe Harte S Signature a Month tDay *Yew <br /> {{jVVy �t•-s�.s. 1 I l . :_A.; .w1eR+v.`. { f <br /> ri 16.International Shipments t <br /> r Import to U.S. w._❑Pxpert from U.S. Pon ofemry/exit _ <br /> 2 Trumpeter signature(ffi exports ady)r Date leaving U.S.: <br /> w 17.TranspoderAcknoMedgment of Ramps of Materials <br /> Transporter 1 PdntedRyoed Name Signature j' y Monty Day Yee- <br /> 0 L2 <br /> J Month Dear <br /> C <br /> Transporter Printed/Typed NeNam �, Signature t( <br /> rG <br /> I <br /> 18.Discrepancy <br /> 18a.Discrepancy Indiz;ron Space ❑ puantiry [:]-type ❑Residue ❑Pallial Rajeems El Full Rejection <br /> Manifest Reference Number: <br /> r 18b..Altemam Facility(or Generator) U.S.EPA ID Number <br /> 3 <br /> U <br /> LL Faclidyrs Phone: <br /> w 18e.Signature at Alternate Facity(Or Demeanor) Month Day Year <br /> 2 <br /> m79.Hazardous Waste Repon Management Method Codas(i.e,codes for hazardous waste treatment tlisposal.and recyUirg systems) <br /> Zo Designoted Facility Owner or Operator CedNme.of romipt of hauNous materials covered by She manifest except as.acted iNrem/86 <br /> illt Printed+rypedName Signature Monty Dar Year <br /> f <br /> EPA Form S70D-22(Rev.8-05) Previous editions are obsolete. - DESIGNATED FACILITY 70 GENERA76R <br />