COMPLIANCE INFO_2018 - Laserfiche WebLink

Home Browse Search

M 45 Irl'"r# P"I it i 9,:rt(Ifn Please print or tvpe. (Form designed for use on elite (12 -Ditch) lvoewriler.) Fnrm Annrnved OMR Nn 20so.on3Q tt-Al-orMbluU-ZZ(Kev a-ub) rreviouseomonsare oosolete• GENERATOR'S INITIAL COPY . ) .'' 7 ' 14773,15155 73,15; 3) UNIFORM HAZARDOUS 1. Generator ID Number2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST ,4> `I'... { � ', t" �, � a C' ` % 9 rj SKS 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) ?Ilf'1' illP!Gtr �.��'V�,3..ty.�[+IA Generator's Phone: r t)." q "' -r ;C 6. Transporter 1 Company NameU.S. EPA ID Number c r 1 !'I YS EPt I NC r TXRt�i0012181 r'05 7. Transporter 2 Company Name U.S. EPA ID Number 1;-.' " 1.rMt!IR0NMEN,rni. sw INC.. 8. Designated Facility Name and Site Address Q EAN 11PRIA] RS A RA6014I Tt-, I I L; U.S. EPA ID Number 11600 NORTH n11ru)a IZIIII10 ()¢tMAIN I IT i 1 Pi E1[lfi P9 1-MMItl"F{T31it,�i'i:''!'t Facility's Phone: ga gb. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (if any)) Quantity Wt.Nol. rz `l`W NON. rt(,rt+t I4,IZARDOI]fi WAMV. i IJI-.1:=.1124 o g [f;I)�!?; (11I:i; OTSTILUITM ,;ill W 2' ,t'1kft WIN- C�tGRA HAZAF�DOU'c' WAS TF. '�l)l. IV5 ' t i 1 I NC; 80ROTF 2.-3,35),-"74)7 • - 3 fh7ttt'. NON -44.11A HAZARDOUS IFII;t'E r K;9. (ASPHOL.T), -Wil --- 4. 14. Special Handling Instructions and Additional Information 211- Hip 1 M1-RCiR4f;Y ill. 013K / TFT I 15. GENERATOR'SfOFFEROR'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, marked and labeledlplacarded, 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 Exporter, I cedify [hal the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. 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 a small quantity generator) is true. GeneraloeslOfferor's Printed/Typed Name Signature Month Day Year 16. International Shrpmenls i El Import to U.S. Export from U.S. - Port of enlrylexh: Z - Transporter signature (for exports only): Date leaving U.S.: W 17. Transporter Acknowledgment of Receipt of Materials a Transporter 1 PrintedlTyped Name Signature Month Day Year O CL Q Transporter 2 PrintedlTyped Name Signature Month Day Year 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity [11 Type El Residue ❑Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J U rQ Facility's Phone: 18c. Signature of Alternate Facility (or Generator) Month Day Year 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) O 1. 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year tt-Al-orMbluU-ZZ(Kev a-ub) rreviouseomonsare oosolete• GENERATOR'S INITIAL COPY . ) .'' 7 ' 14773,15155 73,15; 3)