Laserfiche WebLink
Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />Ll <br />Form Annrnvpri OMR Nn ')nrn-nnqo <br />EPA 1-orm 81OU-22 (Rev. 3-05) Previous editions are obsolete. --rpl <br />h <br />'p, <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page I of <br />3. Emergency Response Phone --F4. <br />—Manifest Tracking Numbed. <br />WASTE MANIFEST&V 1 <br />1 <br />003731 10 3 FLE <br />5. Generators Name and Mailing Address Generators Site Address (K different than mailing address) <br />Ui- JP <br />'j <br />Generators Phone: <br />6. Transporter 1 Company Name U.S, EPA ID Number <br />': — - '-. ,FeE�' I <br />! � - -, ;- r"'r N I !' } <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address r U,$. EPA ID Number <br />iNF' 'S"I M <br />D f. NTf <br />Facility's Phone: <br />9a. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any))13. <br />Quantity <br />Wt.Nol.tY <br />Waste Codes <br />No. <br />Type <br />1. <br />RIG,, WA571-1- tj <br />0 <br />IDIESEL RE GAOILNI <br />2. <br />Uj <br />3. <br />----------- <br />4. <br />14. Special Handling Instructions and Additional Information <br />sill 161111 P#20 P0 �,' 2- 01 t <br />RV* 6 <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of ihisitignment are fully and c felyeMEdal:47e by the proper shipping name, and are classified, packaged, <br />a cura <br />marked and labelediplacarded, 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 certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generatges/Offeror's Printed Signature <br />ITY, ped Name Month ay <br />=j <br />16. International Shipments <br />El Import to U.S. ❑ Export from U.S. Port of <br />Z <br />entry/exit: <br />Transporter signature for exports only): Date leaving U.S.: <br />W <br />LLI <br />17. Transporter Acknowledgment of Receipt of Materials <br />0 <br />Transporter I PnntedfFyped Name Signature Month Day Year <br />Z <br />Transporter 2 Printed/Typed Name bignature Month Day ear <br />18. Discrepancy <br />18a, Discrepancy Indication Space D Quantity FIType Residue E]Parfial Rejection El Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />L) <br />LL- <br />Facility's Phone: <br />018c, <br />LU <br />Signature of Alternate Facility (or Generator) Month Day Year <br />!7C <br />Z <br />1 S2 <br />V) <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LU <br />0 <br />1 <br />1 2. <br />13. <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name Signature Month Day Year <br />EPA 1-orm 81OU-22 (Rev. 3-05) Previous editions are obsolete. --rpl <br />h <br />'p, <br />