Laserfiche WebLink
, <br /> !1!ft Form Approved,OMB No.2050.0039 <br /> Please print or type,(Form designed for use on elle(1�.pitch)typewriter.) "7 2 UNIFORM HAZARDOUS 2.PPhone 4.ManifestTracki (([(WASTE fdANIFE5T Cil! 4'!i?'!1}1r'i r f„ ) ( t.t S <br /> 1,GenamtorlDNu bar; <br /> 5.Generator's Name and Mailing Address Genaretor s Site Address{rfditferentthanmailing addrass) <br /> ���� <br /> 17 ` i$ ,.. �•r'.d. �.:,„ <br /> Generator'aPhone � U•S'.EPA ID Number <br /> G.Transported Company Name ( "( t 41f"E ll�iCt,j <br /> yll" <br /> U.S.EPA IU Number <br /> 7.Transporter 2 Company Name <br /> Iv <br /> y y y <br /> V1111TI l 1111AR??Otri 04VIR {MN('Ak S} rRt y}.FS XME U,S.EPA IDNumber <br /> 6.Designated Facility Name and Site Address AN HARBORS 'SAN JUSt", <br /> Ci�)h� ,3'f3KaC a l"r� ��`..`(.t'�',� „•;rrti�,i•, <br /> Facility's Phone: <br /> 9b.U,S.DDT Description(Including proper ,Ship Ing Name,Hazard Class,1p Number, 10:.Contalners 11.Total 12,Unit 13.Waste Codes <br /> 9a. No; T pa Quantity Wt.Nol. <br /> HM and Packing Group(if any)) y <br /> ht2.1N ffl: # ) };1r'1Z )I (�GTON td�r3rF �it';L.t L)CSs tM1{,j � r! :.•.4 <br /> IN85 'r Z <br /> Z 2. <br /> u.r <br /> 3. <br /> 4. I '�• <br /> I <br /> I <br /> 14.Special Handling Instructions and Addilronal In rmation =7 9nd" t`u • <br /> � Tt��).„iia' � rvt•:n, �.,.� <br /> r'1 F4 t nik t2t;i itiif;l � �, I"tGr3 w_i � Ihrri�t l `4"F C <br /> 1 E 'fOR'Sf p FICA 1 ji:.her y d�re raFln' nt oh i �rl r r� nt 9� d a tare ry 8 rib' 'bo b e pie i Ping name;ardour classified,packaged, <br /> marked and lobelediplacarded,and are in all r aspe?ls in proper condition for transport according to applicable International and national governmental regulations:It expoflsh(pment end am the Primary <br /> Exporter,i codify that the contents of this con Ignment conform to the.terms of the attached EPAAcknowledgment of Consent. <br /> I cerilty that the waste minlmizadon statement ld6niiried in 40 CFR 262.27(a)(if I am a large quantity genafator)or(b)(if f amla.smali quantity:'generator)Is,t�ife. Month Day Year <br /> GeneratoeslOHeror's PilntedlT ped Name Signature <br /> r 16 Inlemalional Shipments Import t U.S ❑Export from U Sr°f Port of enlrytexil: <br /> Date leavingU'S'., <br /> Transporter Signature(for exports only): <br /> i7.Transporter Acknowledgment of Recelpt of Mate Ws Month Day Year <br /> TransportOft edliyped Name ; Signalure <br /> 1 C” <br /> ESigna ure nth ay Year <br />( Q ransport tin edf p Name <br /> F- <br /> 18,Discrepancy <br /> 18a•Discrepancy Indication Space qua City ❑Type <br /> ❑ <br /> Residue Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> 18b.Aitemate Facility.(or Generator) <br /> J i <br /> U <br /> w Facility's Phone: I Month Day'. Year <br /> w 18c.Signature of Altemate Facility(or Generator) <br /> F„ <br /> 19. stems) <br /> Hazardous Waste Report Management Nellie Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling sy4 <br /> u 1 1. 2. 3. r <br /> t:a <br /> 20.Designated Facility Owner or Operator:Cortifiealion of receipt of hazardous materials covered by the manifest except as:nded inatem 19a Month Day`, ear <br /> i PnnteddTyped"Name Signature <br /> = I l l <br /> GENERATOR'S INITIAL COPY <br /> EPA Form 8700.22(Rev,3-05) Previous edition are obsolete. <br /> i <br />