Laserfiche WebLink
Pleaserint or <br /> p type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,+JM9 No.2050-0099 <br /> UNIFORM HAZARDOUS 1,Generator ID Number 2.Page/of 3.Emergency Response Phone 4.ManifestTrackin um at { <br /> WASTE MANIFEST -AL.t4€ 956717 '' 1 4'15-M-8772009 0 ,ter <br /> 5.Generatf s Name and Mailing Address GeneraWsSbAddress(if different than mailing address) <br /> Lff&eIRSAL SkX RECYCLING AArr MIUM W.ndoftwl <br /> 321M S.El Dorado <br /> Sdo6l",CA 9M <br /> Generator's Phone: <br /> o,Transporter 1 Company. ams U:5.EPA ID Number; <br /> WWI PRO&Lines co <br /> 7 Trhnspoder 2 Company Nama U.S.EPA ID Number' .. <br /> 8.Designated Faci''Ay Name and Site Address U.S.EPA ID Number <br /> ECDC EriviromnerlW UT 39i22fJ1 <br /> 111iIVest Hahmv 123 <br /> 441. 1 C ,1,T 84520 EISA <br /> Facilii}rs Phone! <br /> W441-4451 <br /> 9b.U.S.DOT Descrip6en(including Proper Shipping Name,Hazard Class,ID Number, 1O.Containers 11,Total 12,Unit. 13.Waste Codes <br /> HM and Packing Group(ff any)) Na. Type Quantity Wt./Vol, <br /> 1. <br /> o IV..'A'J R'CRAHAZARDOUS WASTE,SOW(i`gt(-rDu 1 fiagUIW 1 001 � � T <br /> LU 2. <br /> E <br /> 4. <br /> 1 p. <br /> 14.Special Handing Instructions and Addtionai Information , <br /> Ery if;640 <br /> 15. GENERATOR'StOFFEROITS 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 labeied/ptacarded,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 certify that the contents of this consignment conform to the terms of the attached EPAAcknowfedgmant of Consent, <br /> I certify that the waste minimization statement Identified in 40 CFR 262.27(a)(it I am a large quantity generator)or(b)(rf I am a smaif quantity,generator)is true, <br /> 9eneratoe giro's not Name__ Mjnatu Monl1i Day 7ear <br /> _ 6.in emational Shi nth <br /> — 11 import to U.S. ❑Export from U.S. Port of entrytisll . <br /> Trans iter ' ature for ex its onl : Date leaving <br /> 17.Transporter Acknowledgment of Receipt of Materials NNE <br /> Transporter 1 Printed(yped Name SignatureI Monthay eat <br /> c <br /> Q 7ransporter2Printedtfy*Nama nature Month Day Year.. <br /> r <br /> 18,Dlscrepancf <br /> 18a.Discrepancy Indication Space El Quantity ❑Type ❑Residue ❑Partial Rejection., Q FUII Rejection <br /> Manifest Reference Number: <br /> 18b,Alternate Facility(or Generator) U.S.-EPA ID Number <br /> c� <br /> LL <br /> FacilitVs Phone: <br /> C3 186,Signature ofNtemaleFad;ty.(orGenertar) Month Day` ; Year <br /> S2 19 Hazardou;Waste Rcpert M-lament Msthod Cgd0g r kates for hazardous waste treatment d'�sgcsai,and to yr&ng j stems), <br /> 1 1, - 2, <br /> 20.Designated Facility Omer or Operator.Certification of loco pt of t azardoUs materials covered by the manifest except as noted is Item 18a <br /> PrintedfTypad Name t _• ignature 67onth D Year <br /> EPA Form 8700-22(Rev.3.05) Previous editions are obsolete.' DESIGNATED FACILITY TO GENERATOR <br /> _ f <br /> a <br />