Laserfiche WebLink
Prease print or tyoe.(Form designed for use on elite 2 )typewriter.) Farm Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS I 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Man(ifft Tray}klrtrg N mbgr r <br /> WASTEMANIFEST C.A. 'ty(A_ f�0 !y4Ci 1 5!A-bei1-i 1ti3 U . V 1_% .t V e. v � FLE <br /> 5.Generaators Name and Mailingg Address Generaloes Site ddress(it different than mailing address) <br /> l,Obinr `ame nrani ni <br /> 20th 2 4d.i <br /> Generators Phone: <br /> 6. f <br /> nsq:0er ompany Name I <br /> `r �4ti+r --httlU(S�a <br /> 7.Transporter 2 Ccmaany Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S. <br /> EPA ID Number <br /> is 1•• i�. .�,�4t tl:ji <br /> )5!r5 i-? '�:► WVT1;1061(t(I4fr <br /> Fadtity's Pncre. <br /> 9a. 9b.U S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> HM and Packing Group(it any)) 11.Total 12.Unit 13.Waste Codes <br /> No. Type Quantity WUVol. <br /> leil„F(((llri 1'Y�l�tifi' '• <br /> ' �iCil:r iDebf?<s) <br /> Z 2. <br /> W � � <br /> � { 7 <br /> � I <br /> I <br /> I ! <br /> t <br /> 14 Special Handling Instructions and Additional Information i <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accuratety,described above by the proper shipping name,and are classified.packaged, <br /> marked and labeledlplacarded,and are ort all respects in proper condition for transport according to applicable intemational 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 EPAAckrvAtledgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large Quantity generator)or(b)(f I am a small quantity generator)is true. <br /> enerato sr eros rime yp ame Signature <br /> Month ay Year <br /> 16 IMemalronal Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entrylexit <br /> Transporter Signature for ex ns ono : Dale leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transp0nen 1 Printed/Typed Name gna ure <br /> 0 .wl ! t1h;�f^:. ono ay ear <br /> IL <br /> U) <br /> Transporter 2 Printed/Typed Name gnalure <br /> ea <br /> H <br /> 18 Discrepancy Month ay r <br /> 18a.Disueparcy Intlip40n Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection <br /> 1 ❑Fuil ReecGor <br /> 16b.A4ernate Fatality(or Generator) Manifest Reference Number. <br /> � U.S.EPA ID Number <br /> U <br /> Q <br /> LL Fsa'.c's Prone <br /> QG 187 SyanaEre of Alternate Facility(or Generator) <br /> Month Day year <br /> N19 Hazardous Waste Report Management Medtod Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLI D 1 2. 3. <br /> 4. <br /> rftte'd <br /> signated Facility Ormer or Operator.Cerlillcation of receipt of hazardous materials covered by the marifesl except as noted In Item 18a <br /> Typed Name Signature <br /> Month Day Year <br /> EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COP- <br />