Laserfiche WebLink
Form Approved,OMB Nd.2650-0039 <br /> Please print or.type,(Form designed.f ususe On elite(12-Pitch)typewriter.) -,: <br /> 1.Generator ID Number Z.Paget of 3.Emergency'Response PfWne `Malhffest r <br /> UNIFORM HAZARDOUS CALOW 1 ;4`15-823-8772 LE <br /> ' <br /> STE MANIFEST <br /> 5. erator s Name Mai rq Address neratots Sita Address{if different than mailing address) <br /> RSAL I� YLttG AtnIliahl dOttC <br /> d{ S:E N , <br /> sltOdhm CA <br /> Generafol SP a: f <br /> 6 ranspWler gt�hpany Name t , '.U S EFA ID Nwd�t ' <br /> tiTt + •kRS III 24 <br /> ,7,Transporter P Company Name U.S._EPA ID Number <br /> 8.Desgnated Facility Name and Site Address U.S.EPAID Number <br /> CDC Eff&0nM&nW UTU930`1220i <br /> i11{ WestH 123 <br /> 'Facil ry's Phone: <br /> 4 i Irate Carbon,U1 26 USA. <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Tota! 12.Unit 11 Waste Codes <br /> No. <br /> HM and Packing Group(if any)) Type Quantity WtNol. i{ <br /> .� '� <br /> EHt�'fUl .: '"•' q., .. ...,«««...FFF^"'^.•,.._:_..,_,. _.�..»,..,. <br /> i <br /> 2 <br /> 14 <br /> V <br /> 3. <br /> 14;Spaaal Hand ohS M Add tianal i,... <br /> tf t 6�L OREM(auw Pilaw, tAH 1pt / <br /> tiS- CRA 41, 17 <br /> 15. GENERATORw5FFEROR'S 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 /> ansportacoo ding to appiitable international and national governmental regulations.it export shipment and I am the Primary <br /> marked and!abeledlplacarded,and are in all respect in proper condition for b <br /> Exporter,i certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of ConSenL <br /> I certify that the waste minimizatlon statement identified in 40 CFR 262.27(a)(if i am a largo quantity generator)or(b)(t I am a small quantity,generator)is true. <br /> ejJf - na Month— a2y <br /> ar <br /> toes, <br /> yp erne <br /> 1 i67inlemational Shipments from U.S. Port of enuytexit: <br /> import to U.S. Export <br /> Transporter s'nature for ax only): ❑ Date leav U.S.: <br /> 17:.TrarsporterAiSaowgf>tep(oERe tofMa'dals j- d ! ''t: s .::. `. monthay ear <br /> Transporter 1 Po yped Na �t <br /> !�ri { l nature ay Year <br /> d Transporter 2 PrintedfTyped Name '9 <br /> H <br /> 16.Discrepancy <br /> 16a,Discrepancy Indication Space Quantity ❑Type ❑Residue El Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> a <br /> 18b.Alternate Fachly(a Genecatpr} U S EPAID Number <br /> �,Facl6 S PIe3 a ia3` v , n Nronfh 1 Y YEaf <br /> y�j; tBc Saxe ' tY for Ctcerator) y s i i +' <br /> ,1$Hazardous tNas#a Reper(6(anagemant Riethod Codas e' ides orhazardoiis waste tfeatmant disposal and 1ec}�5ng systerosy: <br /> 20.Designated Facility owner or Operator:Certification of receipt d hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedrfypad Name gnaWra 10 th Day Yaar <br /> DESIGNATED FACILITY TO GENERATC <br /> EPA Farm 8700-22(Rev.3.05) Previous editions are obsolete. f'r ` <br />