Laserfiche WebLink
Please;print,ort.We.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNI- AZARDOUS` 1.Generator ID Number 2.Page 1 of 3.E er a cy Response Phone 4.Manifest Tracking Number SKS�[(� <br /> ANIFEST 1 � t ®17� a7n�7 <br /> 5: erator's Name and MailingAddress <br /> Generator's Site Address(if different than mailing address). <br /> 1 # TtCate Melden Cate <br /> 18501 wept t r' d R Attu Samuel t h my i 1 Stan' d Rd <br /> TRACY A 95377 TitSam <br /> Generator's Phone: - —3934, TRACY <br /> CA S5377-9,108 <br /> 6.Trans oiler 1 Com an erne U.S.EPA ID Number <br /> QTY_ e , VST INC <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> -LEAS` RRS " RTGd Zt . € t3r; '.r'r,t r(t <br /> 7-.t)esignatetl Faei ityerne and Site Address ,A RR ENV iT -+9R� U.S.EPA ID Number <br /> 2-247 S HY 71 ' <br /> KIMBALL 6914 <br /> 308—' 235-401?, <br /> Fadi lysPhone. 1 <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name," azard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> w No. Type Quantity Wt.NoI. <br /> 1WORM, q0STt (3140L1 I ALIR 9 9 PS 11 P D001 M 13 <br /> Z <br /> LU 717 <br /> c� <br /> 3. <br /> 4: . <br /> 14.Special Handling Instructions and Additional InformationTSDsKP 74266556 AD20198 <br /> � <br /> 4' HR EMEAGENCY #1-860-468-176% (SK / T 1 <br /> 15. GENERATOR'S/OFFERQR'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 andlabeled/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 the contents of this consignment conform to the terms of the attached EPAAcknowledgme'nt 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#small quantity generator)is true. <br /> GeneratoeslOfferor's Printed/Typed Name Signature I Month Day Year <br /> 16.Intern conal Ship ens ^� -✓ r <br /> F_ ❑Import to U'S. ❑Export from U.S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> OTransporter 1 Printed/Typed Name , Signature Month Day Year <br /> 0. <br /> ransporter 2 rintedlTyp d Name U Month Day Year <br /> 18. ancy <br /> 4a <br /> 18a.Discrepancy.Indication Space Quantity ❑Type yp ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Altemate Facilityor Generator <br /> ,( ) x, _- 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 /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. 7 <br /> 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/TypedName Signatur ;jr Month rDayear <br /> a,. J , <br /> I EPA Form 8700-22(Rev.3-05) Previous editions are bsole e. DESIGNATED FACILITY TO GENERATOR <br /> c� <br />