Laserfiche WebLink
U� <br /> �7 �,TIIRODeJa990 5C PPS <br /> Please print or type. (Form designed for use on elite ( 12 •ptch) typewriter ) Form Approved_ OMB No. 20SM39 <br /> UNIFORM HAZARDOUS �O f Q Q 2, Par or 3. E Response Phren d. Tracking Hummer <br /> WASTE MANIFESTCO !/ G + 1 5 . 6Q0 83 �3`� FLE <br /> 5 Generators M Mailing Addie C�� ` ^ C ` tots SAe Address to t than mailing addrosa) <br /> O) .c .Jl 'u J CQl�TL1 i F� 6 <br /> It-I "7 00 sS ch L.�. re C_COf - C3 , 5 ) <br /> Generator's Phone t e a l.� , 1 3 7 7 S 4 - 865 <br /> ran.,6 ny Name U.S. EP/ ID NumbeO 9 r, O <br /> C ( � JUrbt� a�6� Eav � rdnme � +-Qt. �t� ) c. S qac 1/�►/ , lAD <br /> 7 Transporter 2 Company Name U S. EPA ID Number <br /> 8 Design FaaWv Nano and SAa Address �� ,� t 114 l.(.G <br /> CL � ✓ 4 ; Q ( gg �S U.S . EPA ID Number <br /> �n00 W Gsr (�Q e� 6row) c t?o CA T) aBOG'f) t J76 <br /> to Ct3t <br /> 9a, 9b U.S. DOT Description (including Proper Shipping Name, Hazard (lass, Imber, 10. Containers 11 , Total 12 Unit <br /> HM and Pad1,kVGmuP (AanY)) 1 NO Type Quantity WLPM. 13 Waste Codes <br /> 5o Li 0a • SPy (A rd E .� G , CADS t�t, �►-a , Q �m ZU <br /> � s 81 <br /> Z 2 - <br /> W <br /> 3 <br /> 4 <br /> 14 Special HandroInstructionsand AdditionalInkirmatbi • io OO PLC", <br /> 40107 &A&oA <br /> Ik zztfi�t C44 <br /> t . <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare tial the contents of Ilm consignment are " and acardety dwxrbed above by the Proper shipping name, and are classified, padmged, <br /> marked and labeladlpiacarded, and are in aU respects in proper condition for transport according to applicable irn':emaliunal and national governmental regulations It export sfnipirient and I am the Primary <br /> Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAckreMedgmem of Consent. <br /> I ce" #19 the waste minimiratton statement identified in 40 CFR 262.27(x) (A I am a large quantity generator) or (b) (A I am a small quantity genoralor) is true, <br /> ererate s nt am Signature <br /> ear <br /> L o6 12a IS <br /> 16. International Shi nts <br /> Z 1:1Import to U.S. ElExport from U.S. Port of an fowl <br /> Tans iter signstwe for exports only) : <br /> leaving U <br /> w 17 TransporterAolsnoMWgmeMofReceiptofMaWWis <br /> OTransposer 1 tintedayped me <br /> CL UOS 4s� � V 1 � � Y8 1a <br /> co 4 Transporter Prm d/Typed Name rtMmth Day Year <br /> 18 Discrepancy <br /> 18a. Discrepancy Indication Space ❑ Quantity ❑ Type Ll Residue <br /> ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number. <br /> 160. Altemate Facility (or Generator) U.S EPAID Number NEENEEMENE <br /> J <br /> Q <br /> L - 's Phone. <br /> W Fad Signat6,- ture ctARemate Faaiity (or Generabr) Month Day Year <br /> 4 <br /> 2 <br /> U9 19 Hazardous Waste Report Management Method Codes tis,, codes for hazardous waste trea6nenl disposal, and recyding systems) <br /> LU 1L1w , r � 2 3 4. <br /> 26 DeWmtsd Facility Domer or Operates: Certification of receipt of hazardous materials covered by the rnarifest except as noted in tam 18a <br /> Pnn oma maM" Dly Yaw <br /> r <br /> ✓..er7 -� Z-er <br /> EPA Form 8700-22 (Ree 3-05) Previous editions are ob.>olete . DESIO ATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />