Laserfiche WebLink
Plmm nrinf nr hma /Ftir�m Bocinnad fnr uca nn alilo 119 mtr. :awdfar 1o <br />+oA Approved. OMB No. 2050-0039 <br />EPA Form 8700-12 (Rer3--05) Previous editions are obsolete. / f' i <br />N"' DESIGN T D -AL;lLtV TO GE PA F. <br />UNIFORM HAZARDOUS 1 1. Generator 10 Number <br />OAI' <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking umber <br />000358836 FLE <br />WASTE MANH 1 <br />5. Generator's Name and Mailing Address L,, Gen ratofs Site Address (it d' erent than m//a11il�ing address) <br />I FN�tW himba, I�f1dtN J'a `JAII jp[L (4toI S, 11 -mc 161 1C( 1WaArCkms <br />�'� CC <br />.A( .A11) iva�te t acttl4 <br />K f t 1 ' `--3 13f ^ G I�G C'I <br />GeneVu <br />:L+On. L.l GS 0 <br />6. Transporter i Company Nam I - U.S. EPA 10 Number <br />7. Tr_r2C4nyNU.S. PAID Number <br />, <br />71 r" <br />rl s/ rCl7v` �i p <br />8. Designated Facility Name and Site Address I U.S. EPA IO Number <br />1PL11; k1Ci� l:xfS l );U1,-G,;rIIPt1%uI JVe., <br />FlO ► 5��� <br />I I- -7115L <br />7 <br />Faci d 'f�t�cio I i}R- �� 7.J�/ <br />liki'O <br />9a <br />91b. U.S. DOT Description (inducing Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />g <br />��Q nlYittL11 (-, u o CI �, L 0113PG -T <br />N[>`y 3, , <br />`Wt.Nol. <br />a <br />x <br />C {Icolt- t_. S4 4rro i� f5i I Ilatc )Cera I�lg) <br />�:r" <br />bF <br />t' <br />. <br />W <br />2.F {ci,N mabic, Sal urganrc.,NL5,`I'tur,i3,2-5. <br />_ <br />�71P�I�f:S I14 S4 61rwri �IIGteS)C�r� t�3) <br />97 1. VA <br />UF <br />� <br />N <br />Y <br />�� �13"iI i.ATr�3� G1ryY-i i ii/USr✓f.. <br />-VE' <br />Do54 <br />m <br />14.Special Handlingh.� <br />�d nstructions nalh,V...a <br />15. GENERATOR'SIOFFERO SCERTIFICATION: I hereby declare that the contents of this wnsignment are tully and accurately described above by the proper shipping name,and are classified, packaged, <br />marked and Iabeledlplacarded, and are in all respects in proper condition for transport according to applicable International and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I cerfify that the contents of this consignment conform to the tens of the attached EPAAdmowledgment of Consent. <br />I certify that the waste minimization statement ident'rflw in 40 CFR 262.27(a) (H I am a large quantity generator) or (b) (H I am a small quantity generator) is We. <br />GeneratorsOfiemes Printe yped Name Signature <br />month Day Year <br />1 <br />7 --- <br />iQ <br />F <br />16, International Shipments <br />❑ Import to U.S. ❑ Export from U.S. Port of enirylexik <br />hams orter si naNre for exports only: Date leaving U.S.: <br />w <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 Pdnted(Typed Name Signature /o/nn)t ay Year <br />Q.VA <br />RTrans <br />r 2 PdntedfTy ped Name ignatu � �y on ay ear <br />� <br />� <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue &kPardal Rejection ❑ Full Rejected <br />ILl 4 / d Manifest Reference Number. <br />18b Alternate Fablity (or n Generator) 1 ' + (:.� ..� .� U.S. EPA ID Number <br />LL <br />Far,�I s Phone .,` 4 .�'•�+ ; pit N r C i ' <br />w <br />18c 31gneVure ofjdtet9,�te FaPBty(o, G ner r) , --x - ! M n af_. Year <br />h19. <br />Hazardous Waste Re port Management Method Codes(Lii., codes for hazardous waste treatment, disposal, and recycling systems) <br />4. <br />U` <br />20.,Pe31jte6,adiity Ownerar Operator: Certification of receipt of hazardous alerials covered by the manifest except as noted in Item Its i <br />Pdntedrryped <br />in i Si na -'"'^ � ,i Month Day, ear <br />�� r <br />EPA Form 8700-12 (Rer3--05) Previous editions are obsolete. / f' i <br />N"' DESIGN T D -AL;lLtV TO GE PA F. <br />