Laserfiche WebLink
ti 4-1025 <br /> Please print or type.(Form des l ned for use on Bute('12-pitch) writer,) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.GensmWIDNumber ]!its <br /> Paget of- 3.Emergency Response Phone 4.Mao' Tracking Number <br /> WASTE MANIFEST C A R 0 0:0 0 3 4 2 2 3 1 80"24.9" 1016032281. JJK <br /> 5.Generator's Name and Meiling AddresaGenererdYr�s S�9eA�d.dress(gdifterentthan medmg ress <br /> DOM�NOIIMIdGN �aVf@O".I. <br /> 2110+78t Skeet ♦ •< 2810 Im Sk" <br /> 8a kit CA f847i0 Bukaby CA 947% <br /> Gerreretor's Phone: 5 1 0 5 4 1 0809 <br /> 6.Transporter l Company ani r. U.S.EPA ID Number <br /> Fiwk*MWM Logwin,kite. ICAR0002175ill <br /> 7.Tran"2 Company IN U.S.EPA ID Number <br /> ew' or�oors AD03g3aa�S0 <br /> 8.Designated Facility Name and Site'Add U.S.EPA ID Number <br /> i�Era1 Danntr I <br /> FachiWa- a Phone.' SMD n CA 90744, �., AD 0 44429835 <br /> 9a 9b U.S.DOTOescnption(mdudmg Proper Shipping 4me,Hazard Class ID Number. 10.Containers 11.Total 12 Unit 13.Waste Codes <br /> HM and Packing Group(If any)) No. Type Quantity Wt.Nol. <br /> UN2=-VASTE Nonift soklNwo,Wk.t1Aik,(1, r r 331 <br /> o X 8 DNaocyatNloImAw s,�b0oh9mm Oftco wK 8.1,PW <br /> 14.Spacial Handling lnstmctioreand AddNanal Information I CN 1.18 7/7'5.... WIOIt601B81N <br /> 15. SENERATOWSI0PFEROR'$CERTIFICA71(Nl:1 hereby declare tat the contents of this consignment areft*and accurately described above by the proper stuppmg name,and am dassHred;Peakaged, <br /> marked and Iabeledrplacarded,aid are in all respects in proper condition for transport according to applicable Intemetionaland national governmental regulations.Ifexport shipment and I am the Primary <br /> Exporter,l certify that the contents of this assignment conform to thus terms of Me attached EPA Acknowledgment of Consent. <br /> I certify that the waste minlmizatan staternem` gfled in 40 CFR 262.27 a)(if I am a large quantity generator)or(b)(g1 a small quantity genersollripe. <br /> GeneraforslQgeror's Pnntedlfyped Name SggnaNre Month Day Year <br /> ;� i v 17 <br /> 16.International Shipments <br /> i— :❑Importto U.S. ❑Export from U.S Portofem R .... <br /> Z Transposer signature(for exports only). Date leawfgUS: <br /> w 17.Transporter AcknoWedgment of Receipt of M Is . <br /> TranJ$orter 1 Printedrryped Name Slgnatu Month Day Year <br /> Transporter 2 Printedf yped m SignaWre Month Day Year.. <br /> �`� /7 <br /> 18.Discrepancy <br /> 18a Discrepancy Indication Space ❑ Qu mfity [--]Type ❑Residue ❑Partial Rejection ❑WII Rejection <br /> Manifest Reference Number:-. <br /> 186 Alternate Facility for Generator) U.S.EPA ID Number <br /> U <br /> W Faalitys Phone: <br /> W 1so.Signature of XiGmate Facility orgenerator) Monm-,--Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method.Codes(.e.,codes for hazardouswaste treatmentdisposal,and recycling systems) ' <br /> C 1. 2 3 4. <br /> 20.DesignatedFacilityOmeer/oAr Operator Certification of receipt of hazardous materials covered by the man st except as noted in Item Ise <br /> PnntetlRype�N <br /> t EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR" <br />