Laserfiche WebLink
Form Approved.OMB.No,205 •0039 <br /> Reese print or type,(Form designed for use on elite(12,pitch)typffliVellet.)_ <br /> 2.Pa 3.Emergency Respori Manifest IravKtn�NUl11wv1 <br /> 1,Generator ID Number go I of fd Phone 4 <br /> UNIFII�IRM HA7ARDOUS � - <br /> C, El.i�*`111— A I--"I,I ,;",i i <br /> CJOEZ08,284 SKS- <br /> WAVE MANIFI�U <br /> E <br /> 5,Goneraloes Name and Mailing Address Gloneraloe.s'Site Address(If difforentthan moiling address) <br /> Generators Phone: U,S..EPAIDNumber <br /> 6,Transporter i company Name <br /> jj,—Transporter 2 Company Name U.FPA ID—Number <br /> e. a <br /> U.S.EPA ID Number <br /> R;Mi5amo and Site,Address <br /> led <br /> 01 <br /> Facill Phone: <br /> go. 9b,U.S.DOT Description(including Proper Shipp ng Name.Hazard Class,ID Number, 10,C=onlal�n�ersl 1 Total 12.Unit 13,Waste Codes <br /> HM Qua, <br /> and Packing Group(if any}} =N o. Type Quarift wtivol, <br /> 0 <br /> Z 2, <br /> LU <br /> ........... <br /> 3. <br /> te <br /> TI .1—ioll Instructions and Additional InforAI A <br /> I J� <br /> ............ <br /> -15'. GEE 'TDR'SItSFFERD 'S GER i 1 L r0y d Clore InaVil 0 of <br /> 11i1F �nm'e-nt fol son eb Ia ibo.lIl name, <br /> and are ciessi8ed;packaged, <br /> -- nrIlI —,- e <br /> -marked and faboled/placamfed,and are In all rope is in proper condition fortransport according to.applicable Intemallonall and national governmental regulations.If export shipment and I am the Primary <br /> conform to the terms of the attached EPAACknovviedgment of Consent. <br /> I Codify that the waste minimization statement identiled In 40 CFR 262.27 <br /> Exporter,I certify that the contents of this Consignment (a)(if I am a large quantity generator)or(b)(if I am small quantity gonerator).leil <br /> —I — I — Month Day War <br /> pAterdtorslOBerods <br /> �( Signature. <br /> 2—41 1 <br /> I <br /> ,Inl,drry ad Nal <br /> import W.U,S. Efrom U <br /> Export frS. Porl.of entrylexit". <br /> � <br /> I <br /> Transporter signature(for 4 8 Only): Date leaving,U,&: <br /> W 17.TransporterAtknoviledgmerl Receipt of Materials Month Day Year <br /> TraUj —;� , I —nawre <br /> I'll! ad Name Sig <br /> 0 Year <br /> orill <br /> CID <br /> Irons rip rind 741 <br /> 18,Discrepancy <br /> Discrepancy <br /> F]Residue Partial Rejection Full Reaction <br /> r18o,Discrepancy Indication Space F-1 ouall El Type P <br /> Marillost Reli Nu r: <br /> U.S.EPA ID Number <br /> 18b...Alterill Facility(or Generator) <br /> 14, Facility's Phone: Month Day' Year <br /> 0 —1 :17;;Ility(Cr(3eneletor) <br /> ul 0.Signature of erna 0 1 <br /> Z <br /> 19.Hazardous Waste Repo!(Management Method CCI(i.e,,codes for hazardous waste tree.tri disposal,end recycling systems) <br /> U) 3. 4. <br /> nor or Operalor-Certification of rocoljl hazardous materials covered bythe manifest except as noted In Item 18a 20.Designated Facility Ow Menth-7—ay ear <br /> Prints!Typed Namd Signature <br /> GENERATOR'S INITIAL.COPY <br /> EPA Form 8700.22 3.05) Prevlous edition are <br />