Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch)typewriter.) ;tw Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS f } age 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> .H <br /> 1.Generator ID Number 2.P s� Q <br /> WAS T@ MANEFEST / tr 3 1*7 8 1 6 8 JJ K <br /> 5.Generator's Name and Mailing Add . Generator's Site Address(if different than mailing address) <br /> ;�., <br /> ILA <br /> Gen or's Phone: r n <br /> 6.Transporter 1 Company Name U.S.EPA ID Number .+ .? ,4^,' <br /> �I_E�4�i1E�'N Et•?�.°I��'=�.jfulEl�?•; - ---�..,v.m...��a.:�. 'd <br /> 7.Transporter 2 Company Name k U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address U.S.EPA ID Number <br /> RL <br /> w MATH <br /> -- �e�.�l.�: <br /> Fatuity's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste codes <br /> NM and Packing Group(if any)) No. Type Quantity Wt.iVol. <br /> p _ ?. <br /> Z 2. <br /> LU <br /> C'? <br /> II <br /> i <br /> 3. E <br /> 4. <br /> i <br /> 14.Special Handling Instructions and Additions(, ormat on A i F` t? � <br /> Fy � i r �rs''t�'sGLE�`T(a'Ir-tRT#11lw <br /> f 11,..TEW 1 Imo- td5 C7 hit ;�rlCL!!°htT I r. <br /> i4A11i't fir; =r_V4Af•11'P!Ery1-f ly�i-.��tt�Jl�lhl�Pi1 <br /> 15. GENERATOR'SlDFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately.described above by the proper shipping name,aril are classified,packaged, <br /> marked.-and Iabeledlplacarded,and are in all respects in proper condition for transport according to:applicable international and national governmental regulations:If export shipmentand 1 am the Primary <br /> Exporter,i certitylhaithe contents of this consignment conform to the terms of the attached EPAAcknowiedgment of Consent. <br /> I certify that the waste minimization statement identifted in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small`quantity generators is true. <br /> Generators'Offeror`s PrintedlT a Name Signature Month Day Year <br /> ...I 16.International Shipments ` <br /> i- ❑import to U.S. ❑Export from U.S. Port of entrylexil: <br /> Transporter signature(for exports only): Date leaving U.S,: <br /> 17.Transporter AcknoMedgMent of Receipt of Materials x <br /> T ansporer 1 PrinledlTyped Name Sigrnature Month Bay Year <br /> CL <br /> aTransporter 2 PrintedrpName SigtaMonth Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Spade ❑ Quantity ❑Type ❑Residue ❑Partial Rejector ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator? U.S.EPA ID Number <br /> V <br /> LL Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> s <br /> v5 18.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C 1. 12. 3, � � 4. <br /> 0 <br /> 20.Designated Facility Owner orOperator:Ceyti#ication of receipt of hazardous mptrials covered by the r ifestexcei noted to Item 113a <br /> PriritedlTyped Name Signature 1 Month Day Year <br /> EPA Form 8700-22(Rev.3-05). Previous editions are obsolete. 1 — DESIGNATED FACILITYTO GENERATOR <br />