Laserfiche WebLink
7142 { I <br />' F�f'lease print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />f11,.t,, &1788 f -I4 <br />Fnrrn Annmvpd omR Nn gnsn.nma <br />trA 1ormtsFrew ea onsa obsolete. _ PESIGNATED FACILITY TO GENERATOR STATE. (IF REQUIRED) <br />i U7: 16 Y� 11063,1118 �. <br />21 <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />EA L 0 o 0 r 6 7'i "Y... <br />2. P e i of <br />�l <br />3. E fay Response Phone 4. <br />i 1760 <br />Manifest Tracking Number <br />2844069 <br />WASTE MANIFEST <br />T. Genera[oes Name and M 'ling Address Generatots Site Address (f different than mailing address) <br />F. <br />Generates Phone: -ZO `f �, b (,ZZ.2 <br />6. Trans r i Com n Na a U.S. EPA ID Number <br />SAhETY—K N SYSTEMS, INC. TXROSN50930 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address US ECOLOGY NEVADA 1OJVAID Number <br />S OF BEATTY HWY;95 <br />BIt EATILES <br />' 8 9003 <br />800-23973943 NYT330010000 <br />Facility's Phone: <br />9a. <br />915. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (•d any)) <br />Quantity <br />WtNol. <br />0 <br />"NON RCCRRA HAZARDOUS WASE SOLID <br />DM1 <br />,Z� <br />P <br />352 <br />z <br />2. <br />IJJ <br />r7 <br />y <br />3 <br />4. It <br />14. Special Handling Instructions and Additional Information SK SHIP#21< CSG <br />fi[�g- e)Q11 2 J y '7 ty 0 Y k� <br />R6£NCY -CONTRACT <br />#1-800-468-1760 (SRFETY—KLEEP! #94138) <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeledtoacerded, 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 EPAAdknowledgment of Consent. <br />I certdy that the waste minimization statement idenfified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small q generator) is true. <br />Gene s10ff rots PtintedfTyped Name afore Month Day Year <br />Z <br />International ipmerds <br />1:1 Import to U.S. ❑Export fro, U.S. Port ofentry/exit <br />Transporter <br />signature (for exports only): Date learning U.S.: <br />W <br />17. Transporter Acknowledgment of Receipt of Materials i <br />�2 <br />Tran er 1 Print Name Signatu Monthp Day Year <br />� I <br />� <br />/L�/ 9�t ^ LX . ' l <br />a <br />Transporter 2 PrintddfTyped Name Signature Month Day Year <br />t- <br />16. Discrepancy <br />16a. Discrepancy Indication Space ❑ quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />.a, <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />V <br />FacilitysPhone: <br />W <br />18Q Signature of A@ernate Facility (or Generator)Month <br />Day Year <br />Q <br />Z1 <br />0 <br />19. Hazardous Waste Report Management Method Codes (i.e., axles for hazardous waste treatment, disposal, and rerycting systems) <br />LU <br />�C 1 � � � <br />2. T <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 />Ll <br />Nnted/Typed Name Year <br />Skgn Month Day <br />\J � y-` a a � ^ O r <br />trA 1ormtsFrew ea onsa obsolete. _ PESIGNATED FACILITY TO GENERATOR STATE. (IF REQUIRED) <br />i U7: 16 Y� 11063,1118 �. <br />21 <br />