Laserfiche WebLink
P ase print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 12.Page 1 of 1 3.Emergency Response Phone 4.htanlfest Tracking Numher <br /> WASTE MANIFEST ,;,, c - i.:. 011392837 FLE <br /> 5.Generators Name and MailingTd—dress Generators Site Address(if different than malting address) <br /> Pat", @ ! o d V W,Hks4). <br /> !I_. it1 �`�)!�). .t C. FIVE <br /> .,"t <br /> GeneratorsPhone: `-t-i.)t;��.itJ{a: F-I -_- <br /> rensperler mpany Name U.S.EPA ID tJumher <br /> jfiLr'ZCVrI i:)l. t 1a; ir.'• <br /> 7.Transporter 2 Company Name <br /> US.EPA ID Number <br /> tn)i] 'jf!!'.lif!? i{tzf^f}t1 P?� ijtl "i,t?'rii5 I.�-iiti(!I <br /> a.Designated Facility Name and Site Address 1J tf tq{3 (if i {._j j U.S.EPA 1D Plumber <br /> FaclitysPtton��r;; i-.L.-=�;ici"�.ic <br /> oa . _gb.U S:DOT Description(=rdudinr,Proper Shipp[rg Name,Hazard Class,ID N tuber, 10.Contaicars }t.T tan try.Unit <br /> ,`yht and Packing Group f'd any)) Na Type QuarLty Vit vol i 3.Waste Codes <br /> wiasit B� .iU!.3_Li ,._-_�tJ:, l <br /> O <br /> Z 2. <br /> w <br /> CD <br /> 3 <br /> '�.Special Handling Instructions and Additional Information _ <br /> Ilr-firm; .-,;iix I:Pul1•..1 Ci ca lli:Lf_t'3) <br /> 15 GENERATOR'SIOFFEROR'S CERTIFICATION:i herebydedare that the contents of this consignment are Fully and accurately described above by the proper s;ipping name,and are classified,packaged, <br /> marked and lateted%placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regufetinns.If expo.",shipment and I am the Primary <br /> Experter,I cer5ry that the contents of this consignment conform to the terms of the attacked EPAAcknowledgmenl of Consent. <br /> I cer6ty[bat the waste minimization staterrenl identified in 40 CFR 262.27(a)(if I am a iarge quantity generator)or(b)(f I am a sura-1 quantity generator)is true <br /> Genarata'Ofemrs Fortec. yp d.ame ignature w_1+or(r Day :ear <br /> 16.International Shipments ❑x„n from U S. Poi;of act exit. <br /> I- ❑Import to U.S. ❑_p'. ry` . <br /> Z Tranafforter signature(for exports only): Date leaving U.S_: <br /> W 17.TransporterAcvww edgmert of Receipt of Materials <br /> Transporter 1 PrintediTyped Name Sigrixure i f Month ay Year <br /> z r spddsr7 Pri ti /ped Ndrsignature h ortb - ay eat. <br /> Ia.Discrepancy ,} <br /> 18a.Discreparcy Indication Space ❑ Quantitj ❑Type ❑Residue ❑Partial Rejectfor ❑Fu!I Rejection <br /> :tamfest Reference Number. <br /> F 18b.Alter:ate Facility for Generator) U.S.EPA ID Numtter <br /> J <br /> U <br /> Q <br /> LL <br /> Facility's Pure: <br /> w 13c.SnatureoiAllernate^acilityfaGererairH) Month Day par <br /> Q <br /> Z <br /> C7 19.Hazardous Vlaste Repo:!.klarrgarrant Wfod Codes(i.e.,codes for hazardous was'.e treatment,disposal,and recycfirg systems) <br /> UJ <br /> 0 1 2. 3- <br /> 20.Designated Fac:[ity Ow-rar or Operator.Certification of receipt of hazardous materials wvered try the manifest ex ecit a .oted m Sem 18a <br /> F me d Nam= Si afar Month Day Y-aar <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. i:r� 1(=cit i E!;f 'f"_' -Y i 0 mus)"itJAT n-li SPATE(IF REQUIRED) <br />