Laserfiche WebLink
S �- <br /> a=` <br /> Please,print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Peg 1 of 3 Em r e cy Res=ponse Pktoge_, 4.Manifest Tracking Number <br /> WAVE MANIFEST <br /> I 10 60 SKS <br /> 5.Gener$tor's Name and Mailing Address" <br /> i CxCk r rt G s' Generator'sSite Address(if different than mailing address) <br /> j (sT(v)wV-1 — <br /> e , <br /> 1 WC-15t W q'pif'ar, Rd Attu Samuel ojf<I'cnwj REV50i °rtan oird Rd <br /> TRA <br /> CY CES 95`x'1 a (i i �r; �s r G �i� �rc�iz; <br /> * - •^ En , GSI .c t 1 i + ,•, <br /> Generators Phone: 0e, Tt�. 4''' <br /> 6.Trans o er 1 Com a e - U. r EPA ID Number <br /> SYSTEMS I MC) RtiE(`tr J 0r <br /> 7.Tra orter 2 Company Name U.S.EPA ID Number <br /> C—,U (I r I I L' "]!� 3 <br /> 8.Designated Facility Name and Site Address c.° _ S S T T N U.S.EPA ID Number, <br /> 6000 8103TH STREET <br /> t't 4a i�.eii . r 7 CA Y1.:3�011"�(' <br /> 9116"•s:?C"i.-491 <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Mste Codes <br /> HMand Packing Group(if any)) No. Type ' . ;Quantity Wt,Noi. <br /> Z 2. <br /> UJ <br /> 9 <br /> t" <br /> 3. <br /> 4. ` <br /> 14.Special Handling Instructions and Additional Information qq' t r` j �t xss EWtt t y €; Ppp t' ` j 5 <br /> S FtC YiP.tL t o min <br /> d.-.' C <br /> L <br /> 24 OR EMERGENCY 01-000-46f-1760C89 17D <br /> > <br /> ( J.( <br /> AUTH AS "AGENT—FOR" OY BEI-J TO RETAIN <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that thecontents of this consignment conform to the terms of the attached EPA Acknowledgment of Conspt. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(x)(if I am a large quantity generator)or(b)(IfAm a small quantity generator)is true. <br /> Generatoesl0 roes PrintedlTyped Name Signature '' Month Day Year <br /> V (30 ) <br /> �j 16.interna al Shipm is <br /> F Im rt to U.S. ❑Export from U.S. Po of entry/ it: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials aA ` <br /> t2 Transporter 1 Printed[Typed Name Signature j Month Day Year <br /> �, <br /> N ,� t e � ) <br /> Q porter 2 Printedrryped Name i s ure Month Day Y r <br /> P14 T <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El <br /> Quantity ❑Type El Residue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator)' k=> U.S.EPA ID Number ; <br /> U <br /> Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> F) 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> UJ 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name r r' Signa ur Month Day Y ar <br /> 16rmX��:•;. y <br /> 60- ( � Previous editions are obsolete.� ED FACILITYTO GENERAT R <br /> 22 R 3 05 DESIGN T <br />