Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approvkd.OME�-.;Vo.2050-0039 <br /> 1.Generaum <br /> Generator ID Number 2.Pa''e 1 of 3.Err�er�envy Regponse Phone 4.M c � �y <br /> UNIFORM HAZARDOUS �J ~469--17f-,O �,� � <br /> WASTE MANIFEST r. ` <br /> 5.Genamtors Name and MaJVQ Address Generators Site Address(if different than mailing address) <br /> CA S i v.2 <br /> Generator's Phone: 0?'`' _!.'i4 7-'!r�n:i <br /> 6.Transporter 1 ComM NaameU.S.EPA ID Number <br /> 'ii.a .Z�e �Q-j EMS 1 INC. <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address�_ � � {.e U,SID-Number <br /> -4ikt�.-µ''c5•' a! ` - " 117iitT,' ., = .y l <br /> FacAllys Phone: ' <br /> 9e, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13 Waste Codes <br /> HM and Pacldng Group Cd any)) ::. No. Type Quantdy WtNol. <br /> w a» r <br /> LU <br /> 2. <br /> c� <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additibtial Information' I p# <br /> �� rte p;E '4s t1< t; 3 Cr •:# t,XEN 9-4,13 <br /> ,f"7jt I��i tit 3.t TV 080 `:,} is tit:lL.W i.`WZiERSAX41Wf6t 4I.474 <br /> t a8'�.1•'1��.a��T.�J�•�rY��?� <br /> 15. GENERATOR'SIOFFEROWS CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to:epplicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAdarowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 28227(a)('d I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> enerato sl ros PrinteNdiTyped Name E Signatufa onDay <br /> Year <br /> ILL- <br /> J 116.k>tenabonal Shipments ^=" <br /> Import to U.S. ❑Export from U.S. Port of entrybrit: <br /> Transporter signature for exports only): w\. Dete leavf S;-•,, <br /> LU 17.Transporter Acknowledgment of Receipt Qf Materials <br /> Transaorter 1 Pnntedrryped Norma _•� On ay <br /> ear <br /> d rh '.r.' f'• M� r r" "w, '� ..uy•+ ,^,mow r''•• a 's li.-, �' <br /> Q Transporter Prints yped Name ordh ay ear <br /> 18.Discrepancy a <br /> 18a.Discrepancy Indication Specs ❑ ❑To- ❑Residue ❑Partial Rejection ❑Full Rejection <br /> NNnifW Reerence Number. <br /> 18b.Alternate Facility or Generator " y"r t U.S.EPA1 iJriih6er <br /> Q <br /> �- <br /> I--itys Phone: <br /> LLS 1tk.Signature of Alternate Facility(or Generator) Month Day Year <br /> t- <br /> Z <br /> VS19.Hazardous Waste Report Management Method Codes(i.e.,codes for.hazardous waste trealmen-,disposal,and recycling systems) <br /> G 1. 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 /> Pdntedfryped Name Signature Month Day Year <br /> EPA corm,8kQ0-22 (Rev„3-0�) P�ywt�s editions are obsolete. GENERATOR'S INITIAL COPY <br />