Laserfiche WebLink
Please print or type. Form Approved.OMB No.2050-0039. <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.page 1 of 3-Emergency Response Phone1' 01470594.0 <br /> .Manifest Tracking Number WASTE MANIFEST " . r,' FL E <br /> 5.Generators Name and Mailing Address Generator's Site Address(if d:fierent than mailing address) <br /> 1 f Ftp hC <br /> rptocktpT, CA <br /> Generalnrs Phan e. 2011401114M 1 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> AdW--)Cad 010611 TM%pod bX.IDi A AC'Tw wro X70W <br /> T Transporler 2 Company Name U.S.EPA ID Number <br /> ftmo sty syswm, he CARGOM75422 <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> PYI 1 - LILC <br /> AZPKM515W4 <br /> Fadill rs Phone. <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. ' Type Quantity Wt.Nol <br /> -RCRA Hazwdn.t.:Wim,UqW4 KAxAnK ) 13M I b P . 136 <br /> W <br /> L `� l Wim,Lkp" I P 135 <br /> 1.0F5 6 4 <br /> 1 <br /> alb BC 25 ARIA 3iS }Ae. <br /> Y ; DM � p <br /> 4KarRCRANaurdms Walde Said(FAs"y Cunwiii GM f P 3& <br /> l <br /> i <br /> 14.Special Handling Instructions and Additional Information <br /> PM10d Imdw 24M1D 0XMM"t <br /> -�� �7 ��I1fY d u, #X -55- �-OT 11". ._ 3) W151I W- Js� <br /> JP.1 <br /> 2) 13!3712 Jif'1� JX S'S . 0 �OOli75 AtY + <br /> 15. GENERATOR'SIOFFEROR'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 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 <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)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Gen rators/Off s Printed ed Name Sig ture Mon h• Day Year <br /> ,_j ".16.'IntEfmational-Shipments . - - <br /> . ❑Import to U.S. ❑Export from U.S. Port of entrylexit: _ <br /> ? T.ranspohe'r signature'(for exports onl#i <br /> Data leaving U.S.: <br /> 'W. t7:TransporterAcKnowledgmenttof Receipt,of Materials <br /> Transporter t P nted/Typed.Natne .. Si nature <br /> � 9 Mont ayco <br /> . Year <br /> Q Transporter 2 Printed/Typed Name Signature Mo`nth Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity LJ Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> i <br /> Manifest Reference Number: <br /> � 18b Alternate Facility(or Generator) U.S.EPA ID Number; <br /> U <br /> LL Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month, Day Year <br /> a <br /> z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLI <br /> Fnd,/.T <br /> gnated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the man-crest except as noted in Item 18a <br /> err Nama Signature Month Day Year <br /> EPA Forni 8700-22(Rev..42 17) PFevious editions are o solete. DESIGNATED FACILITYTO GENERATOR <br /> 3 <br />