Laserfiche WebLink
Form Approved.OMB No,2050-0039 <br /> UNIFORM HAZARDOUSerge-a ResDonse Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 77=" 1JJK_ <br /> Genera&s Site Address(if different than mailing address) <br /> U.S.EPA 10 Number <br /> U.S.EPA I D Number <br /> U.S.EPA ID Number <br /> -aza-: ass D 10.Containers <br /> 1 Total 12.Unit <br /> 13.Waste Codes <br /> No Type Quantity Wlivol. <br /> LW <br /> Z <br /> LU <br /> i . <br /> lid <br /> 7 - ---- - — <br /> I . <br /> 1GESERA-CR S 0"EROR S:ERriCAT110z:..:e:a­_:'B::-e S -a,,- a-,c accurately described above by the proper shipping name,and are classified,packaged,- T-i1 ­ : <br /> 7: a�cccable:-le-na:ional anc national governmental regulations.If export shipment and I am thePrimary <br /> nm <br /> %'-e:A—s ­e a-,a:7ec c!Cor ant <br /> , <br /> a:arce za.. <br /> aram,;cr(b'(;f am a small quantity generator)is true. <br /> S Gnatz;,_ M onth Day Year <br /> Z Ex-:-.`-^ Port of entry.,exit: <br /> Date leaving U.S.: <br /> cc <br /> LLJ <br /> Month Day year <br /> 0 <br /> Month Day Year <br /> 18.Discrepancy <br /> 189.Discrepancy Indication Space <br /> L_j Quanl* El Type ❑Residue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> C 18b.Alternate Facility(or Generator)_ U.S.EPA 10 Number <br /> 4X <br /> LL Facility's Phone: <br /> Generator), <br /> 18c.Signature ofAftWate—Facility(or C <br /> Month Year <br /> Day 1 <br /> 19.Hazardous Waste Report Management Method C*(i.e.,codes for hazardous waste treatment disposal,and recycling system) <br /> inUj <br /> 1. — 1 2. 3. _T_ <br /> 20.Designated Facility Owner or Operator.Certification f receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Nnte67ypsd Name Signature Month 0"' <br /> Year <br /> Kforrii 8700-22(Rev.3-05) Previous editions are bsolelle. <br /> TRANSPORTER'S COPY <br /> 990/9ZOIA ONI SOAS ANH MAONHHA 66VCSVVLOLT YVA OZ:9T TTOZ/ZZ/90 <br />