Laserfiche WebLink
• � • <br />Please print or tvoe_ (Form dasianed for use on elite (12 -titch) Nnewriter.l <br />Form Approved. OMB 16205=39 <br />EPA Form 8700-22 (Rev, 3.05) Previous editions are obsolete. TRANSPORTER'S COPY <br />UNIFORM HAZARDOUS <br />1. Genera- ID Number <br />2. Page 1 of <br />3. Emergency Response Phone7011272121 <br />Manifest Tracking Number <br />J J K <br />WASTE MANIFEST <br />_ ,tr?( ter ; � - <br />- w T iy <br />5 Generators Name and Mailing Address Generator's Site Address (if different than marling address) <br />Sth�Cr! :�Tv'Eht� TI—P3 <br />Generators Phone: 5- M2a r3W9 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />.alp?ry43 � ;~3he.Fr, 1114: r.:��;ahtladlriiy <br />7. Transporter 2 Company Name U.S. EPA ID NurrMar <br />8, Desnabd Faally Name and Site Address U.S. EPA ID Number <br />a V1 Na e an Add ess <br />rite <br />t r irR <br />Faol s Phone: ALX 3^018? <br />ga <br />9b U.S. DOT Description (including Prow Shipping Name. Hazard Class, ID Number, <br />10. containers <br />11. Total <br />12, Unit <br />13. Wasla Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />rz <br />z <br />,. p1110 i RCRA [-'ltZAP.V0US )tt. '.AXV c �aiar; <br />,. <br />r.: r <br />0 <br />W <br />W <br />2. a 'iK?Sia. Kazmtwn WASTC LQM (IN" 3111 <br />TT <br />u i <br />1+ <br />3 <br />4. <br />14. Special Handling Instructions and Additional Inkirmahon <br />�'Q # 171 t"e ONCE Z <br />'tiT:rR^.l.u�.'L-�S -6 T <br />15 GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare duet the contents of this consignment are kfiy and accurately described above by the Oroper shipping name. and are classified, packaged, <br />marked and labelediplacarded, and are in hW respects in proper condition for transport according to applicable international and national governmental regulations. If exporlshOwt and 1 am the Printery <br />Exporter. I certify shat the contents of this consignment conform to the terms of dw attached EPA Acknowtedgnwrrt of Consent. <br />I Canty that the waste minimization statement identified in 40 CFR M -27(a) (if I am a large quantity generator) or (1 1(it l am a small quantity generator] is true. <br />Day Y <br />o titYearGenMe tate Offerors Pit Nana Signature Mon <br />16. Intematanet Shipments <br />❑ Import to U.S. ❑ Export from U S. Pon of entryiexit <br />Transporter signature (for exports only) Date leaving U.S.' <br />IX <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 rint aped Name Signatu7 / Month Day Year <br />Q <br />;CCT-"'r1Lse.SL�i / <br />CL <br />,a,,�/"''+,^'r'4 <br />Transporter 2 PtintediiTyped Name signature Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quamty, ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. A temate Facility (or Generator) U.S. EPAID Number <br />V <br />Facfilys Phone: <br />W <br />180. Signature of Alternate Facility (or GeneraWr) Montt Day Year <br />=C <br />y19. <br />Hazardous Waste Report Management Method Codes (i.e., codas ler hazardous waste treatment disposal, and recycling systems) <br />G <br />1s !' <br />3. <br />4. <br />T <br />((!Facility <br />20. Deslgnaled Owner or OPerebr CerMM Wn of 8teipt Of hazardous materials covered by the Mn" except as ncW in 18a <br />in yped Narrro Signature Day YeIar <br />EPA Form 8700-22 (Rev, 3.05) Previous editions are obsolete. TRANSPORTER'S COPY <br />