Laserfiche WebLink
Please print or W.(Form desgned for use on to(12-pitch)typewriter.) Form <br /> Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Gdnerala ID limber 2.Page 1 of 3.Emergency Response Phone 4.Man" umber <br /> WASTE MANIFEST 01604316 JJ K <br /> 5.GenemWs Name and Mailing Address s S (d different than maifng address) <br /> wr � . <br /> WE <br /> P <br /> ;ta . -. „- <br /> US EM Mu�6At <br /> x CJrI_80041�{ <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> nr^r3.. <br /> LLC <br /> 4 .U.&EPA <br /> CM <br /> �.CA ftm <br /> P=W,%W611- <br /> 9a. 9b•U.S.DDT Desaofen#Wwft Proper S*ft Name,Hazard Cbs%1)f4wdab 10.Cootamers 11 Total 12 Unit 13.waste Codes <br /> HM and Pa'i`g Qum Clary)) No. Type Quantity V&AAul. <br /> 0 1. tK*i•i(`Pa.Heowtiom W -rids uwft wslstid Dsbf} / CSA <br /> m - <br /> z Z. <br /> LL, <br /> 3. 1 <br /> 4. - - <br /> 1 ) <br /> 14.Special Handling Inshuclions and_Adddiawl In ation <br /> E-FtG ar i?t(Prpflbt�C�!'41BS'11!�B}(tk•dsr* � �--,(�.� — � �� �; <br /> W�ifar Pta�per•€�P.E <br /> 15. GENERATOR'SOFFEROWS CERTIFICAT*N:I hereby dedare that the contents of this consignment are fully and accurately described above by the proper sipping name,and are classified.Packaged. <br /> marked and Iabeledlpla zl,and are in all respects to proper condition for transport acoadirtgAvappficable intemabonal and national governmental regulations.K export shipment and I am the Primary <br /> Exporter,I certify that the contents of this oonsignment owfurm to Ithe teras of the attached EPIAtIftwledgmerd of Consent. <br /> I certify that the waste rrunimazbon stalement' in 40 CFR 26227(a)(d I am a large quantity generator)or(b)(KI am a small quantity generator)is true. <br /> e <br /> Generatoe&Uffrors Printed/Typed Name Signature Month Day Year <br /> .� � w Q� •I <br /> -J 16.Intemational S(yprnaft <br /> H ❑Impart to .S. El Export from U.S. erhtrylexl <br /> Transporter signature(for exports only) Date leaving U.S.: <br /> 04 17.Transporter AduwMedgmant of Receipt of Materials <br /> Fa' Transporter t P±mtedflyped Name signature Day Year <br /> O <br /> asej <br /> QTransporter 2 Printed/Typed Name Month y Year <br /> j18.Discrepancy rr,, <br /> 18a.Discrepancy Indication Spare ❑ Ou.t y ❑Type ❑Residue ❑Portal Rejection u Full Rejecion <br /> ., Manifest Reference Number. <br /> 18b.Altemate Facility(or Generales) i U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generaloo Month Day Year <br /> I � <br /> Z <br /> rn19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Uj 1. 2 3 14. <br /> 14 <br /> 20.Designated Facility Owner or Operator:Certifcaboh of receo of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedlTyped Name Sigmknre Math Day Year <br /> 22 1 3 <br /> EPA Form 8700-22(Rev.3.05) Previous editions an obsolete. DESIGNATED FACILITY TO GENERATOR <br /> .s <br />