Laserfiche WebLink
f <br /> Please print or type. <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUfa1G, la . � . ;.:. �.s.,,. . � 4.Manfest Tracking Number <br /> � <br /> WASTE MANIFEST 0 2 0 0 12 3 J JK <br /> 5.9m,rVcAiNa q r, V 4 Li-C; Generator's Site Address(if different than mailing address) <br /> Irh)7 is VVA1 ERt_(X)R0AD <br /> SFCXf KTOt4 (;A tFo <br /> Genoratofs Phone, U 19 '} `1 I i 0 9 i <br /> 5.Ta U.S.EPAW t, 'o I I 0 i <br /> 7.Tr�xns r2 Com Name `�/ p� U.S.EPA IDNumber <br /> 7ti tiJi'[I,.C��fYl1. �- t� lrl\i SYr�' IEPA IN( i� <br /> t.� A <br /> 8.Ljen �{ilgref Site Address U.S.EPA ID Number <br /> HVVY 9b 11 M1 5(A BE.Ai F e <br /> BE-ATT' NV 139W3 <br /> Facility's Phone: <br /> ga. gb.U.S.DOT Description(induftg Proper Shipping Name,Hazard Class,ID Number, 19.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> - No. Type Quantity Wt.No1- <br /> '. <br /> C7 <br /> z 2. <br /> w <br /> C7 <br /> 3. <br /> 4, <br /> 14.Special Handling lnsbuctions and Additional Information - <br /> iii'.rets#H.k3ti�15riWf� fkAiray3),�Nlrilyti.Hp'H 4_Iti'u;Ilt.�'di'4i' 9i-'.s� <br /> 15. GENERATORVOFFEROR'S CERTIFICATION: I hereby declare that the contents of Ibis consignment are fully and accurately described above by the proper shipping name,are are classified,packaged, <br /> marked and Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable International and national governmental regulations.If export shipment and I am the primary <br /> Exporter,I cerlity that the contents of this consignment conform to khe terms of the attached EPAAcknowledgment of Consent <br /> - <br /> I certify that the waste minimization statement identified In 40 CFR 282.27(a)(i1 I am a large quantity generator)or(b)(ii I am a small quantity generator)Is true. <br /> Generalor'slOfferor's PrintedlTyped Name Signature Month Day Year <br /> r <br /> 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entrylextl: <br /> 2 Transporter signature(for exports only): Date leaving U.S,: <br /> U.] 17.Transporter Acknowledgment of Receipt of Materials <br /> � <br /> Transporter 1 PrintedfTyped Name Signature Month Day Year <br /> O <br /> a. <br /> Z Transporter 2 PrintedfTyped Name Signature Month Day Year <br /> E- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ quantity ❑7 ❑Residue Partial Rejection <br /> Type ❑ 1 ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Altemate Faoillty(or Generator) <br /> U.S.EPA ID Number <br /> U <br /> W Facility's Phone: <br /> w 18c.Signature of Allemate Faciftty(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> co <br /> UJ G 1. 2. 3. 9. <br /> - -.7 <br /> 20,Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as rested in Item 183 <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete, GENERATOR'S INITIAL COPY <br />