Laserfiche WebLink
Please print or type.(Form detigned for use on elfle(12-pitch)typewriter.) - Form Approved.OMB No.2060-0039 <br /> UNIFORM-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Man Trackin�jNumber. <br /> WASTE MANIFEST CAd-O iU355717 t i 3823 9 72 f, 6752 L <br /> 5,Generators Name and Mailing Address nerators Site Address(ff diferent than mailing address) <br /> L!MVERML SvC ReCYCUM Alis WHOrn Mendon0a <br /> 3244 S.EI Evado St. <br /> Stoexten,CA <br /> Generators Phone: <br /> Transporter 1'Company Name FSIEPA ID Number <br /> Union P ift bires C0J NED=7929W <br /> T 7ransporfer.2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address ,. U.S.EPA ID Number <br /> at <br /> ,Ur?--0930 12201 <br /> 1111 West HVW'My 123 <br /> Faoiliiys Phone: <br /> 1 East Cwbw UT 84520 USA L <br /> go. 9b.U,S.DOT Description(inoluding Proper Shipping Name,Hazard Close,10 Number, 10.Containers 11,Total 12,Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity. WtNoi, <br /> R d:6.J PSP'�rhm t4a`YR9"sYYF`�441°�1g1➢Y+'YX" C aAi.... KrYY`.`_ <br /> o r:.aawr t.'"rtwraa�Lts�rta WAnIa, ttwif- llit tcf9w ) WV1 rtes f� <br /> x 2: <br /> w _ <br /> t7 <br /> 3. <br /> 4, <br /> 3� <br /> i <br /> 14.Special Har dCing instruclians and Additional Information <br /> SOVICE RECYCUW PROJECT RAVW NO, <br /> Ed1 t6 ohm <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fillAnd 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 applicable international and national governmental regulations.if export shipment and I am the Primary <br /> Exporterj cerfly that the contents of this consignment conform to the terms of the attached EPAAciuov{edgmant cit Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 26227(a)(rf i am a targe quantity generator)or(b)(d I am a small quantity generator)is true. <br /> Gane torsi s ypad Nama gna an ay ear <br /> :' V7 117 <br /> r 16,International Shipments <br /> I ❑Impo t io U.S. ❑Expert from U.S, Port of an*#,—" <br /> ` <br /> Transporter signature LOT exE rtsonl : .e Date aLLI <br /> '.tk <br /> 17 Trartsj aarterAcl i avifg rent of iece pi of Malerrai "` �s a:l ,.., x 6k, «,,> tr ar- ;x n ; <br /> Transporter 1 Printedfiyped Name nature ( on ay ear <br /> r O i <br /> 0. t nature Mon y Year <br /> Transporter 2 Prir fedlfyped Name 9 <br /> F- <br /> 18.Discrepancy ff�� <br /> 18a.Discrepancy Indication Space El Quantity ❑Type 0 Residue ❑Partial Relectian ❑Full Rejection <br /> Manifest Referance Number, <br /> 18b.Mtarrote Facility(or Generator) U,8.EPA ID Number <br /> .:r <br /> Fak7' s Phona:. , <br /> w, ftSignature,ofAtemateFara;iiy(or Generator) <br /> Month ;.Ory Year <br /> Q' <br /> 19,Hazardous Waste Report Management Method Codes(r,e„codes for hazardous waste treatmenfi disposal,and recycling systems) <br /> f. 2. 3. 4, <br /> 20.Designated Facility Owner orOperator.Certification of receipt of hazardous materiais covered bytha-man'dest except as noted in Item 18a <br />` rinted[T pad Name gna Month Day Year <br /> i o o ° ) <br /> EPA Form 8700.22(Rev.3.05) Previous editons06—olosoliffle. DESIGNATED FACILITY TO GENERATOR <br />