Laserfiche WebLink
Pease print or type.(Form designed faruse on elite 12 Itch ^' <br /> P )ty writer.) ' <br /> UNIFOIi'INHAZARDOuS I.GeneratorlDNumber Fame <br /> WASMNANII 2.Page 1 of 3.Eme APPfOVW.OMB.No.. ....; <br /> P=� 158BS�d rgencyResponsePhone 4.Men st7rackt Number <br /> 5.Ganeratar's Name ami MaatingAddress ` <br /> OWA# � - <br /> P. .Bt3iti Generate's58eAddress(ifffensntihowni ipngaddnsss) R <br /> WOCKTON,rept 112D j;,��"li.m viii.i' <br /> Generator's Phone: i"�L"i�'1�5Pi,t3,% <br /> 5.Transporter 1P�yName" <br /> " �t <br /> � <br /> I <br /> 3i9t#yt;ITEC: U.' EPAIDNumber ' ) <br /> 7.Transpwter2 <br /> Can! Name <br /> Wt c#fq <br /> 8.Designated F ty Nama and SMeAddress N�an!>er l <br /> U.S.EPANf. <br /> U.S.EPA ID.Number <br /> Fa <br /> s Plane,' r.4.1i } +�E1h7il3t�w5q, <br /> ga. ob.U.S.[)DTDesaipSon <br /> t{M and" Pfd Shipping Name,Hazard Class I _R <br /> tunber� <br /> P (dVGraq►(KanY}) <br /> tOrCoatahters 11:Total <br /> fUGf� ACtf:::: - Quantity WtNo1112.Un <br /> t 13.Wash Codes <br /> gyp. A f^".&. RddUS bWayl~ f}E95 <br /> EC##.4 Atj <br /> :.. P <br /> 3. <br /> _ I <br /> 4. i <br /> i <br /> • � .1?M" ALTT R�wt� •� <br /> 14.3pedai Handling htsbuctions andAddlBoneP Pnfortnation <br /> 1= P t71 <br /> WEAR all yrs�t i Q,. 9't�► `*�T�w•. ."'�` f4rf+d�CE� !` <br /> 15. GEbIERg70R'SloFFEROR'S CERTIFtCATiGN:#herebq dedare that the contents of Phis con mneM are # ��^" <br /> marked and la6eledlptacarded and are M all respects In propercondition for fu8yand acaaately desmibed atmve Pry the proper <br /> Exporter.'I ca*gmi Ste contents of Ihls twm**aomWfng to applicable InMii*ndatd natkmaf gom mentai g"name,and rad +' <br /> I"cet8fy that Ste wasro m �' the.terms of the attached EPAAdotowWgmentaf CormenL eti0a�gexPart shipment and I am the primary•' i <br /> ktGnlzaBon statement identiti In 40 t <br /> Generator efoffames t } 282.27(a)fir I arl large quantity generator)or(b} I am a stt>ati 9vartEYgenerator)is Due. <br /> • �Lam[ ��t .-� (,... '• (;.: f Signature ,' <br /> 18.IntemedonatSidpmen[p s- #I' ,r ' +� - M Day Year I <br /> Transporter signature(for exports h to U.S. !J Export from U.S. Port of entry/ea ®� <br /> �Y$ 1 <br /> 17.TransporferAdmonq�gm�tofRec tofMaterieis DatelealUS... <br /> Transparter 1 <br /> Signalise <br /> Ttan�"0 ypedNarno Month Day Year <br /> Skill <br /> Is.Discrepancy Harriet ,Dai Year <br /> 88.Descro ancy hedication Space .. <br /> Quantity Q1ype El le <br /> 1 <br /> Pallial Rejection ❑FW R**' n ' <br /> 3b.Altemate FaC7ily(or Generator) <br /> Manifest Reference Number. <br /> U.S.EPA ID Number <br /> .c8ily's Phone: <br /> C.5ignatwa ofAitemate Faa7ily(orGenerator) <br /> i <br /> Month Day Year <br /> Hazardous Waste Report Management Method Codes(Le.,codes farhazardaus waste troatmenL <br /> . disposal,and real systems)2. <br /> I <br /> 4. <br /> Desighated Fall Owner or operatorCertirrcation of <br /> le ame ; Al of hazardous materials covered by the manifest except as mated in item 18a <br /> :`• ,;'"-` - .- •i/Y Signature ..� �,.. <br /> Month Day Year <br /> n 8700-22(Rev.3.05) Previous emons are obsolete, f <br /> i L) /C. <br /> _— ___. _ ;$ iilSt�tw?R ER'S COPY <br />