Laserfiche WebLink
5� qM fq2WV <br /> Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved, OMB No, 2050-0039 <br /> UNIFORMHAZARDOUS 1 . GeneratorlD Number 2. Pagegl of. 3. Emergency Response Ph one 4. ManifestTracking Number <br /> WASTE MANIFEST . e{• ,�� n ° , " 008701 4 JJ <br /> 51"Ge�ae� mtot's Name and Mailing Address Gener ors Site Address (if different than mailing address) <br /> L� <br /> Generators Phone: c @ 'Q <br /> 6, Transporter 1 Company Name p 0.S. EPA ID Number <br /> a' V'1K: LLY•86'Y a <br /> 7. Transport r2 any Name U.S. EPAID Number <br /> B. Designated �� <br /> d�� Facility Name and pSite Address ae U.S. EPA ID Numhor <br /> cwjv"r Vi 44k,3�Y7�y6�t�� a.w6Frrt/•� iWd. . <br /> till s�hon,e� 1 a16 <br /> 9a. 9b. U.S. DOT Description (Including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11.Total 12: Unit 13. Waste Codes, . <br /> HM and Packing Group (if any)) No. Type Quantity WtNol. <br /> 0 1 6 Amok- Dew WAVW, de wcw <br /> 2• & <br /> 3. <br /> 4. <br /> t <br /> 14. S ecial Handling Instructions and Additional lnforri ' <br /> �w-�alz � <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 latieledlplacarded, and are in all respects in proper condition for transport according to applicable intema6onal 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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement Idenfified In 40 CFR 262,27(a) (if l am a large quantity generator) or (b) (if l am a small quantity generator) is We. <br /> GepneratorsfOfierdes Printed/Typed Name 6M ,[,�y�.+L �yyk Slgnatum Month Day Year <br /> 16. intemadanal Shipments ❑ Import to U.S. ❑ Export from U.S. Port orenhyleAL <br /> 1DateTransporter signature (for exports only): leaving U.S.: <br /> our 17. TranspoderAcknowledgment of Receipt of Materials <br /> Tran derl Pdnfedfryped Name / Signalum Month Day Year <br /> N - ��` ✓ Monh Day f e <br /> ar <br /> Tmnsporter2 Pantedlyped Name Signaturea <br /> K <br /> F- <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space El Quantity El Type ❑ Residue El Parini Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternale Facility (or Generator) - U.S. EPA ID Number <br /> J <br /> U <br /> r+a- Facility's Phone: <br /> w 18c. Signature ofAltemate Facilily (or Generator) Month Day Year <br /> R <br /> Z <br /> 19. Hazardous Waste Report Management Method Codes (i.e.. codes for hazardous waste treatment, disposal, and recycling systems) <br /> 0 1. . 2. 3. 4. <br /> 20. Designated Facility Ownerbr Operator. Codification of receiptofhaz ous materials cove red by the manifest except as noted in Item 18a <br /> Pdntedlfyped Name 'n Signature Mo h 0 y Ye� <br /> 9 V <br /> EPA Form 8700-22 (Rev. 3-05) Previous ad ns are obsolete. fY paap�lA FACK + ` 0012 OR9MON STATE (OF RE�flDV� � �r <br />