Laserfiche WebLink
Tease nrint nr tune_ (Form desioned for use on elite (I 2-nitth) tvnewn er 1 <br />is Fnrm Annrnved OMB No. 2050-0039 <br />UNIFORM HAZARDOUS <br />t. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />_1 <br />4. Manifest Tracking Number <br />0 0 0 3 5 8785 F L E <br />WASTE MANIFESTCAR <br />t` 0Q <br />b <br />5. G erators Name and Mailing man Addres ATT���3hr �ite Addr(if different than mailing address) <br />dE Nou�eh <br />old l da j yks+�3cou utwy(A <br />l SIO NZL ct111• <br />I -6m CA aq5 i i ` RA brie 6 S rNcU - <br />Genera <br />6. Transporter 1 Co pa Name U.S. EPA ID Number <br />10f ni, <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Z si nated Facili Name a Site Addr <br />q� Iv �Jf'rutC.� U.S. EPA ID Number <br />� 'r <br />� H ertC� ��'Ctt?, <br />�.Id bj� r ►-�30 <br />Facility's Phone: ® l - 1 L4 q <br />9a. <br />HM <br />9b. U.S. DOT Description ('including Proper Shipping Name, Hazard Class, ID Number, <br />and Packing Group (f any)) <br />10. Containers <br />11. Total <br />t2. Unit <br />13. Waste Codes <br />No. <br />Type <br />Quantity <br />Wt.Nol. <br />,. famlma�l� i....►Q ua /� N•C7S•,3, un�R��, �G �" <br />,� <br />l <br />N <br />X <br />C��l a�11� �UCe�oUt� },CC'rr� : a� �QF': loSq4T4) <br />� <br />LLJ <br />2.i1_ in` KCIQCI!QTC r 10.�� �Gt <br />X <br />f�j�ii�cA <br />C�cn-�Sa-t►�a��fCeISA:Ia F'� ► cam) <br />�F <br />7 <br />4kaC6 tYIA -ertGt; 3; u��db3; ads <br />-A 13) CPFI-1gg5a1) <br />to 2,4i <br />\ <br />')rlell0 <br />j� <br />rit <br />!V <br />4. <br />14. Special Handling Instructions and A itional Information <br />a-) 7"1g5ac-3)`1`t�15a7 xss �m <br />-oat X 1 ya <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: 1 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 labeled/placarded, 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 We. <br />Generator Offerors Printed/Typed Nameigna e Month ay ear <br />Wtt- ? V� 1a t� o� <br />-i <br />1-- <br />K <br />16. International Shipments <br />❑ Import to U.S. ElExport from U.S. Port of entry/exit: <br />Transporter signature for exports only): Date leaving U.S.: <br />17. Transporter Acknowledgment <br />W <br />of Receipt of Materials <br />it <br />CL <br />Transporter 1 Prmted/Typed Name Sign lure Month Year <br />LA <br />Jay <br />v^Gtiv1 <br />Q <br />Transporter 2 Prmted/Typed Name ig ure Month Day Year <br />t- <br />18. Discrepancy <br />18a. Discrepancy Indication Space Quantityf <br />El ❑Residue � � vection <br />''` <br />�'i7 <br />Manifest Reference Number: Ts 1) 18b. Alternate Facility (or Generator) <br />J <br />AIN <br />wd tlde� Iti <br />r+ <br />W <br />Facilit 's Phone: p)Mu ! <br />18c. Signature of Alternate Facility (or Generator) t la �j <br />a <br />Z <br />ry Year <br />L� cli <br />Fn <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />0 <br />1. 2. 3. 4. <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name Signature Month Day Year <br />:DA <br />P- a71)n. 91 ID-, 1 Arl D-,; ... ..At; ...,..., I I <br />"" """ _. -- -- %"-,." V " '"" ""'""" "'" "" DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />