Laserfiche WebLink
x---� RECEIVED BY SJCEHD (EF) ON 2/5/19 <br /> ! kk I <br /> SK. E;HIP# 22449@534IN III I III <br /> Please print or type.(Form designed foruse on elke t12 P" ter.) 0 G b 3 2 5 7 9 t) 5 K S <br /> Farm Approved.OMB No.2050 fl039 <br /> UNIFORM MANIFEST 1.Generator ID Number CAD982485,351 2.Pigg 1 of .(r { p� 4.Manifest Tracking" Number ) <br /> WASTEtI EST ;Fs 006325790 5 KS E <br /> and FAailirg Generator s Site Address[M different than meii ng address) <br /> �!1"Pin I14�"' Lodi CW5 <br /> ��!•� � Pine G �'� <br /> Rw .DI CIS 9524@-311I18 <br /> venerator's 2�5-�33:I�-C��3 <br /> 1�Zit'TEM INC U.S.EPA rD Number ??4 RI0f8115 <br /> T CLA 2 HA ORS ENV I RONMENTAL SVC INC. U.S.EPA ID Number <br /> 8. CiD0353n250DesugnatedF 'v11Igmeand <br /> NRRA I t 1 Cr If!IShE[I f CipJ U.S. awNwt�,er <br /> 3 MILER EART, 7 MILES NORTH KNOLLS EXIT 41r OFF 1--80 <br /> 435-884-8915 KNOLLS UT 84083 <br /> FadB s Ptwne: UTD991331748 <br /> 94. Sb,U.S.DOT Desafptiat(irrduding PrOWShippirg Name,Hazard Class,ID Nambar, 10-Containers <br /> HM and Pig Group(Many)) 11,Tatai <br /> 12.tint 13.Waste Codes <br /> Nt N RCRA IIAZRRI?tjub WASTE SOLIDS, No. ���Typ + ,llty WLNd. <br /> (14015ORBENT AND 01 L), -NI � �/�� P 352 <br /> till —� a c,— uC 1 <br /> juC 2. <br /> 3. ( <br /> 4. <br /> T4--J. HtaXMVftxEructionsartdAddl4ormlfnf1,111 ar T iI):01M 79-086957 CA479ba <br /> 24 HR EMERGENCY #1-800-468-1760 (CH / SK I TFT) <br /> SEE ATTACHMENT 1-7o Z7 <br /> 15. GENERATOR'SlOFPEROR'S CERTIFICATION: It f ereby declare that the contents of this canstgnment are fdly and accurately desdibed above byr the proper shipping name.and are ed, <br /> marked and laheiedlplacarded,and are in 81 respects in proper condition for transport ac=ding to applicable inleru valarid national rernrtlerttal <br /> Exporter,t ver*that Ore contents of this cons gement conform to the terms of the attached EPA Acknowledgment of Consent. re9� -if export sbipMent and I am the Primary <br /> I certify drat the waste min' ization I Wenufied in 40 CFR 252.27(a)(if I am a large quantity generator)or Ib)[sit am a small quant ge is true. <br /> Generators e s PrintadiT N <br /> S nacre rr Month pay Year <br /> art to U.S. <br /> ❑Export from u.S_ Port of entrylewt <br /> Transporter signasure(for extorts ), Date leaving D.S.: _�_._.--.---.-- -..-- <br /> 17.TranWor(erAcknowfedgmertt of Receipt of Mat 643 <br /> Tra r 1 Prihtedff Signature <br /> Mail th Day Yea <br /> Z Tm ypad dame 1 <br /> Signature , Year <br /> t8-QiscrepanEy <br /> iiia.Disvepancyr Indication Specs ❑ t7uamity ElType ❑Residue <br /> ❑Partin ReIa. ❑Ftdl Rejection <br /> 18b,ARemaw Fadiify dor Generator) Manifest Rekerettce Number <br /> a U.S.EPA ID Number <br /> Li <br /> 6�r- i=aciity'S Phpne: <br /> 18c.Signature of Alternate F8c lity(a Generator) <br /> Ittonll Day Year <br /> 19.Hazardous Waste Report Management Me-hod Codes ti.e.,codes forhazantous wast—traamwL disposal.and recyc6rxl systems) <br /> LU <br /> 2. 3 <br /> A, <br /> r <br /> 0,Designated Fac>kty osurrer orcWLajor <br /> Prig Certification of receipt of haxsNoue ma6Dfiafs covered the Arered f <br /> es rsded in!tent 18a <br /> E7)F��3 (lFtev 3 51_�T� sedttftmsareobsaleta. GNI�TE[}FACILITY TO DESTINATION STATE(IF REQUIRED. <br />