Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch)typeF�rn;ApProved,OMB No.2'v50-0039writer.) <br /> UNIFORM HAZARDOUS i.;enenwcr ID Number 2.Page 1 of 3.Emer,ency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST y �11 7'7P 0113 8 5119 F L E <br /> 5 Gererator's Name and Me fing Address enerela s Site Address(if different than mailing address) <br /> L;a$II A Doliv t-l01-6=- 1510 Bath $ Lad:' t•1cI i:r kii510 <br /> :094729339 ft`J50 PACIFIC AVE. VIEBERSTOWN MILL/ SWAGE 4950 PACIF=IC AVE <br /> Generator's Phone: 1:;1' C ' ' CA . 5 <br /> 211)7 <br /> 8. rnnsporler i Company Name U S EPA ID Number <br /> E" <br /> f. _ r .a..: _ <br /> r'•�� '!11.9-i I.-f <br /> 7,hanspcner 2 Company Nan:= 7.5.EPA 11;rlumber <br /> l'laf td'.•lICiei(f:;0 1 `J-V t@11_ ofl1i -bei2, <br /> R.Designated - <br /> ac,Fy Nano and S to rddress U.S.EPA ID Numter <br /> 1+!I0.y `i Eie. L1 <br /> '30 E. 13th 3tr'eet <br /> 1/-i' 8530.5 • <br /> Fac;StysPhore '.12864:38`333 AZR+DO051 5924 <br /> ga 9b U.S.COT DesCripllch(inctudn:g Proper Shipping Name,Hazard Class.ID P:c^1cer, 10.Containers 11.Tota' 12 U. it 13.V,aste Codes <br /> HM I <br /> and Packng Grwc(If ar:y)) No. Type Quantity <br /> 11Yun RLRFt h jai do+.+s !daEl'e, Iiq+.lid r5oar; l 1:+FCr <br /> i <br /> Z 2 <br /> W <br /> 3 <br /> I <br /> i I <br /> 14 Special Handling lrstmctions and Additional lnfcm><ilicn <br /> 1, 11091i12('3tate Regulated Liquids) <br /> 15. GENERATOR'S.'OFFEROR'S CERTIFICATION: thereby declare that the ccn!wls of this consignment are fully and accurately desr-ribed above by the prover sh voirg damn .and arc•dessirwc oackageC <br /> married and lobe ed'{acardr:d.and are in all respects in proper condition for transoon accorai•g to aopizable fntematanai and naliarai ver'nw:al regulatkris If exacrt;Ic;,rre 1 Sad'ar'l"ir P•:ra <br /> Exporter.I M.-Ii6y that the contents of finis consignment conform to the terms cf 1113 attached EPAAcKnow edgmenl of C "nt. <br /> I cartify that the waste rmcmizalion statement Identified in 40 CFR 262.271ar(if 1 am a large quantity generator)or(h it t a a sma nlily ge/. ra' .).s true. <br /> er for i, era's n ted�yped ami signature CL o l F of Liallt�� cr.t 1 a;; ear <br /> r,. n �F' <br /> .01 <br /> -•-r 1G.Intemalional Shipments Ell import to U.S. ❑Export from U.S. Port of entryle'l: <br /> z Dato leav S.: <br /> Transaorter si nature for exooas onl l: <br /> 17.Transpoder Acknowledgment of Receipt of Materials r <br /> fW Transporter 1 rir'.edi yped Name Sign lure nt ay ear <br /> o <br /> D. Anthwiv MackEn <br /> .1,,:-111 Cn•; Year <br /> re,vlypenr:amr ana re <br /> Z Tit^spertcr 2 ar+ i <br /> 18.Discrepancy �} <br /> 18a.Discrepancy Indicalion Space (El Quantity ❑Type ❑Residue ❑Partial Refection ❑Full Rejection <br /> Manifest Reference Number: <br /> N U.S.EPA ID Number <br /> 18b.Alternate Facif:ty(or Generator) <br /> J <br /> U <br /> LL <br /> Facittvs Phone. klonth Day Year <br /> LLA 102.Signature of Alternate Facility(or Generator) <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> N <br /> 3. 4 <br /> LI 1 <br /> W 11 <br /> -4�)v' I <br /> 20.Designated Wily Owner or Operator:Certification of recut of hazardous materials covered by the manifest a cepl as noted in Item 1 a. Month Day Year <br /> Printedtlyp Name , re <br /> oA Form 810 22(Rev 3-01 Prev ous editions are obsolete. !?i:;1!=.NATED FACILITY'i 0 DE i INA7IUiN S'I:II'i'E(II 1iCQU1P.EC) <br />