Laserfiche WebLink
F <br /> please print 6r type. Form Approved,OMB No.2050-0039 <br /> liN1FORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFtST VAMi if 7 a+d 021989255 JJ <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> jr/FtgTRI r��t((Pint i. <br /> .'i1�$i ,A"1i�AErf�,�4�t+/IV�•lY. <br /> Generator's Phon' (52 <br /> 6.Transporter 1 Company Name' U.S.EPA ID Number <br /> f�7a�`fi"ECI.fIUIEMMA a els ld 14�f tnr� lf, lrlf);1 <br /> 7.Transporter 2 Company Name U.S.EPA IQ Number <br /> 8.Designated Facility Name and Site AddressAASMS r-MARCININ&WAL Stt VIC.4:i l4,ft•. U.S.EPA ID Number <br /> t-1510 q1AX.4111 RKepl NEI <br /> i,VIEMT%A gA1Y1 NTfD,4A $!" ?1 <br /> FacilllysP.hora: ;$ f <br /> ga, gb.U.S.DOT Description(including Proper Shipping Namo,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HIMand Packing Group{If any)) No. Type Quantity Wt.Noi. 13.Waste Codes <br /> 1. Wli J �! 17tr.��i.3400us 7wi ,�f:13„1ll (OIL @Em lam) 4 r � � <br /> Ix a <br /> n <br /> cFj <br /> Lu <br /> .. <br /> 3 <br /> 4. <br /> 14.Special Handling Instructions andAddilional l6fomiatioo <br /> .EA, <br /> �.YM1M a�,i f�'PSt(�1+.(��`#..,4.# j \t$i��¢a��gg�r``[{a�� p�� rL} $ ENC-4171 <br /> {4.i5� t''1Jf1� g�.:'E1t P �Ai=3{k:;�ph, M+1� 'III(NO PMSGn- <br /> t~AMM-Ar '5*1.1ULD IiM'$"t ANE'D AND 1AN-1.APPli RVIl f <br /> 15.. GEN£RATOR'SrOFFEROR'S CERTIFICATION; I hereby declare that the contents of this consignment are fully and a=rately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeledlplacarded,and are In all respects in proper condition for transport according to applicable internationaland national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform 10 the terms of the attached EPA Acknowledgment of Consent. . <br /> I certify that;the waste minimization statement identified in 40 CFR 262,27(a)(if I am a large quantity generator)or(b)(if I am VmaV quantity generator)Is true. <br /> Gen atoslOferorsPr€ntedlTypedName Signature ;bx hf. Monttr Day Year <br /> f A- <br /> J 16.International Shipments <br /> iy ❑Import le.U.S. ❑Export from U,S. Port of ertrylexit: <br /> Transporter signature(far exports only). Dale leaving U.S.: <br /> w 17.Trarsporler.Acknowledgment of Recoipl of Materials <br /> Transportef 1:1'rintedlTypedlyame x Signature Month Day 'Year <br /> Transperter 2 Prtrtedff•yped Name a £ � ) nature-Si R * 1 <br /> g Month Day �Year <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity L1 Type ❑Residue El Partial Rejection El Full Rejection <br /> i Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S,EPA ID Number <br /> V <br /> rar� Facility's Phorre: ' -� h•, <br /> 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(f e„codes for hazardous waste treatrrienl,disposal,and recycling systems) <br /> UJ <br /> 3. 4. <br /> 20.Designated Facility Owner or,Operator:Certification of receipt of hazardous materials covered by the manifest except as nand in Item 18a <br /> PdritedlTyped Name Signature Mont Day Year <br /> EPA Form 5700.22(Rev.12-17) Previous editions are obsolete, GENERAT'OR'S INITIAL.COPY <br />