Laserfiche WebLink
1 <br /> PO <br /> Plense print or type.(Form designed for use on eli16(1 -pitch)fypewritorPr� �� �����;?�rr� j Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS I.Generator 10 Number 2.Page of 3.EmprgencyRosponso Phone 4,Manifest Trac fggq Number <br /> WASTE MANIFEST C1It..rt)!P,�-146360 � i..���,,.k�;�'-�7f� 005361066 SKS <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> C'i4c."rs Flit, systvvq Incl214 874h l`� 0,PY <br /> 1 r�TatRECEIVEO MAY I <br /> Generator's Phone; 9 16-444-2523-i <br /> G,Transporter 1 Company Name U.S,EPA ID Number <br /> T;t€i0 00001,�0 <br /> 7.Transporter 2 Company Name v U.S,EPA ID Number <br /> 8:Designated FacliltyName and Site Address { �( ��RBORS + �1' F LLC <br /> U,S,EPA ID Number <br /> CA 9513306-441.--0'`J{;= A174� ' 'a�}31r <br /> Facility's Phone: <br /> ga,`' ft,U.S.:DOT Description(including Proper Shippir Name,Hazard Class,ID Number, 10,Containers fi'.Total 12.Unit 13.Warta Godes <br /> HM and Packing Group.(if any)) -- <br /> No. Typo Quantity Wt,rVai. <br /> x ) :1 ;eta A ;it3�AR ARMUS WASTE SOLIDS, DIN P Pt <br /> cr (OE,"O' SS PE:Ti �( UIN ` <br /> ! Y✓ i <br /> w 2. <br /> t9 <br /> 4, <br /> 14.Special Handling instructions and Additional Interm'illon 5 P .w f <br /> 1793 <br /> #V g, -i7fl 'l AV lwf+'. Tfl 17 :_ t:.p,'N 2;, <br /> 15. GENERATOR'SIOFFEROR'S'CERTIFICATION:i hereby declare that the contents of this consignment are fully and accurately described above by the preper shipping name,'brd are classified,packaged,: <br /> marked and labeled/placarded,and are in all respects 11 proper condition for transport according to applicable International and national governmental regulations.It export shipment and I am the Primary <br /> Exporter,i certify that the Ontents of this consignment onform to the terms of the attached EPAAaknowledgmentof Consent. <br /> I certify that the waste minimizationnstatementide tiff In.40 CFR 282;27(a)(if I am a large quantity gone(Nor)or()Alf l am a small quantity generator)is true, <br /> en tor'slOfferoes Printedrryped NameSign h e. Mogrth Day Year <br /> .. 11 <br /> j 16,International Shipments <br /> t- ❑Import to U,S. I 1 Expod from U.S. Porkof entryto <br /> Transporter signature(for exports only): % Dalri eavlA YUS" <br /> 17,TransporterAcknowledgmenlafReceipt ofMaterials <br /> aj <br /> Transp PrintedlrypedName Signet rhibnih Day Year <br /> Z . <br /> v <br /> Z Tr—ansp6rf6riPXntedrryp6dNanie Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy indication Space ❑Residue <br /> Quantlty� ❑Type. ❑Padial'RnJecUon ❑Full Re;ecliom <br /> Manifest Reference Number; <br /> 18b,Alternate Facility(or Generator) U.S.EPA IO Number <br /> t� <br /> u`'-. Facility's Phone: <br /> in <br /> 18c.Signature otAlternale Focility(or Generator) Month Day Year <br /> H <br /> t19.Hazardous Waste Report Management Meth d Codes(IA,codes for hazardous waste treatment;disposal;and recycling systems) <br /> 1. 2. 3. q, <br /> f t16 <br /> 20.Designated Facility Owner or Operator,Colliicalfon of receipt of hazardous.materials covered by the manifest oxcept as noted in Item ilia, <br /> Prints.fryp d Name l� �: S>lg!n 6, j `'. Month Day Ye <br /> EPA Form 870022(Rev3.05) Previouseditlonsar obsaete. — 1�IGN' EDFACILITYTOGENERATOR <br /> i <br />