COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

6X SHIP# ?,2925�86 Form Approved.OMB No.2050-0039 Please print or type. 2.Pag 1 of 3.. m9Fgpp,�Rg ppgqpp66e,Fhone 1, Nffi n Number 1.GI'llenerator ID Number �' 4t a Ca,rtl" dkGi"' P C5 195 2 SKS UNIFORM HAZARDOUS E��'1i�E3t ��' aI SKS WASTE MANIFEST Generator's Si a Address(if different than mailing address) S.Generatoee4c and Mailing Address I..i11t:?s CA:a a �<fl3�'?10t1 Rr S S Ft MCIA I am 209- � .--„i r?' Generators Phone: U.S.EPA ID Number g� ��.N�� 6.Tr�n&t r ft—aT U.S.EPA ID Number 7.Transporter 2 Company Name ciF I f l``Ira r l Li , q• , U.S.EPA ID Number 8.Designated Facility Name and te Address } _ r�, �I.r'ltd'4t�tF1'+S f tfw e r Facility's Phone: 10.Containers �^ 11Jotal 12.Unit 13,Waste Codes 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, No. Type Qu• fity Wt.Nol. HM and Packing Group(if any)) 1 Yii� 4�i Rfit HZAIR )i I 0 ce t' USEDC�I.L. f.t Z 2 W C9 3, 4 14.Special Handling InstructionsadAdditional Informatiol A I,.4.,,a; (� a + nn s,,. 041 EMER.GER4C:t �f3..��,,H�`�ii�./R&Y-•3;.0�'i';,>"�az r�"'i•�`y `�,� 1�� 4��t��s'��tstt� ::�+a�t�'T' �ti,+;��1� � ` rs l i r1f1!.,f d�# .P� on 0,11 aak4iAl tta 5p �f ter yd�3 cts Mtlt� "fia�1art �xcl( .. �s�; �. 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and�.ccurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable internal oral and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Goisent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b);if am a small quantity generator)is true. Month Day Year Generatorsl0fferor's Printed/Typed Name Signature 16 International Shipments ❑Import to U.S. ❑Exportfrom U.S. Port of entry/exit: Date leaving U.S.: Transporter signature(for exports only): , W 17.Transporter Acknowledgment of Receipt of Materials Month Day Year Lou Signatyre" } .' Transdorter 1 Printedlryped Name a 1 Signature MDay Year onth Z Transporter 2 irintedffyped Name 18.Discrepancy ElRe,idue ❑Partial Rejection ❑Full Rejection 18a.Discrepancy Indication Space ❑ Quantity El Type Mani'est Reference Number: fw U.S.EPA ID Number 18b Alternate Facility(or Generator) J e .. U tai Facility's Phone: Month Day Year W 18c.Signature of Alternate Facility(or Generator) Q Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recyci ng systems) 4 UJ 1 2. 3, D ' 20.Designated Facility Owner or11 Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Month Day Year Printed/Typed Name Signature GENERATOR'S INITIAL COPY EPA, 1r0raii,8�7,Q0 Rg . a-�7} �,evious editions are obsolete.