Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Trackln,Number <br /> WASTE MANIFEST C 1 �Q I�L- � r?� 000461171 F L E <br /> S. drillers Name and Melling Address //�� c ,y Generatorss Site <br /> 'Address(it different than mailing address) <br /> {� ..�C_agU 4!� l_U VVltt.i 5� �. �P'l)4. �(' Ju.� J IJ 1) �t0 �g" n <br /> ��•(��` 3oxgine <br /> + 1 0l <br /> GeneraWr�' rfoe. d <br /> 6.Than spo rI Company Name U.S. PAI umber <br /> 0 In <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Acp-(C coni inc. . _ <br /> Facilitys Phone: kauwand At -1 ,(151 (Aaq— 11A( 1 7T, L4 R aLA { _d -1 <br /> ga 91b.U.S.DOT Descripti (including Proper Shipping Name,Herded Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(Hang)) No. Type Quantity WiNol. <br /> 1 Q 70blyehlor (natPrl 3iphfN13 )Solsdl C1i <br /> r DM 115 U311;: <br /> z 2. <br /> W > : <br /> 3. <br /> 4. <br /> r <br /> 14 Special Handling Instructions and Additional Integration <br /> G Q.G <br /> 1-7 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of 01's7consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in propercondition for transport afcording to applicable international and national gqg mental regulations.If export shipment lam the Pdmaiy <br /> Exporter,Icertify that the contents of this consignment conform to the terms of t6 911ached EPAAcknowledgment of Consent. ` <br /> I certify that the waste minimization staternai t identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity genl;catopyls true. <br /> Generolorsl 5 erors Printed/typed Name igna ure n ay Year <br /> I ' 1 ��c1 ff ,r- A)vvi a_v\Z vim_ � � - � -- .. . ��_. .�� -7 Oct <br /> —1 16.International Shipments <br /> � ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> ? <br /> Transporter signature for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Pdnted/Typed Name Signature Month Day Year <br /> QTransporter 2 Printedryped Name Signature Month Day Year <br /> 1Y <br /> T18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) US.EPA ID Number <br /> LL <br /> Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> In19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste Vestment,disposal,and recycling systems) <br /> Let <br /> C3 1 / P 1 Ell 1 <br /> 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed sed me Signatuy Month Day Year <br /> EPA Form 8700-22(Rev.3-0 ) Previo s editions are obsolete. /DESIGN' D FACILITY TO GENERATOR STATE(IF REQUIRED) <br />