Laserfiche WebLink
f Tease print or type. (Form desiqned for use on elite (12 -Ditch) tvoewnter.) <br />Form AL)nrnvpfj OMR Na 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />UNIFORM NAZAROOUS <br />1 Ge ncratur ID Number <br />Emergency Response, Phone <br />14�'W—anifest Tracking Number <br />WASTE MANIFEST <br />77 <br />FLE- <br />5. Generator's Name and Mailing Address Generator's Site Address (if different than trading address) <br />1�*- WA ��,ivcman k lltlii <br />8`mkkw, CA ftlft <br />Generator's Phone: <br />6 Transporter I Company Name US EPA ID Number <br />7 Transporter 2 A ID Nom <br />pmpany Name U.S, Ep,� ID Number <br />8 Designated Facility Name and Site Address U S EPA ID Number <br />'44v"mo c2A%,T ", Irwomt-ft <br />lriisl ttftf, 6&6, NX <br />ARXA*R419L4q,,87 e 01� <br />Facility's Phone: <br />9a. <br />0b, U.S. DOT Description (including Proper Shipping Name. Hazard Class, ID Number, <br />10 Containers <br />11 Total <br />12. Unit <br />11 Waste Codes <br />No, <br />Type <br />HM <br />Tend Packing Group (it any)) <br />Quantity <br />Wt IVOI <br />0 <br />2 <br />LLJ <br />OCT <br />"M MR 7 <br />11 6 2015 <br />4 <br />E* !R <br />'NMENTAL <br />4 0 -t4 <br />C77)nPT%ACNIT <br />14. Special Handling Instructions and Additional Information <br />P1 t A <br />, <br />ply <br />ACTUM R,�, -C; <br />T <br />A) <br />15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately descnbed above by the proper shipping name, and are classified, packaged, <br />marked and labelediplacarded. and are in all respects in proper condition for transport according to applicable international and national governmental reguistrons. If export shipment and I am the Pdmary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) lif I am a large quantity generator) or (b) If Iam a small quantity generator) is true. <br />_qe5ieriar's Printed/7ed Name— Signature ay Y <br />=.j <br />1.— <br />16. Intemational Shipments <br />0 Import to U.S. ILI Export from U.S Port of entryl x1t: . ..... <br />K <br />I Transporter signature (for exports only). Date leaving U.S. <br />.SIX <br />IX <br />LU <br />17 Transporter Acknowledgment of Receipt of Materials <br />l'— <br />TlipqSpo todfjyted Name,year <br />1 Rrin Mo Dly <br />0 <br />ir. r <br />Z <br />Transmaer 2 PrintedlTyped Name nth Day Year <br />18. Discrepancy <br />18d. Discrepancy Indication SpaceF rr <br />D Quantity Type Residue Partial Rejection Full Rejection <br />Manifest Reference Number: <br />>- <br />18b. Alternate Facility (or Generator) U.S EPA ID Number <br />Facility's Phone: <br />LC3 <br />Lf <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />119. Hazardous Waste Report Management Method Codes (.e codes for hazardous waste treatment, disposal, and recycling systems) <br />3. <br />4. <br />20 Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 188 <br />Prtnled,Jyped Name Signature Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />