Laserfiche WebLink
Please print or type. 0 0 7 0 4 0 3 4 3 S K S <br /> Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number `; A - 2.Page,1 of 3 F�inaI Rrx se P,rona 0.Manifest Tracking Number <br /> WASTE MANIFEST - + +''� OS�(� <br /> S.Generetofs Name and Marling Address Generators Site Address(if different than mailing address) 1� <br /> Generators Phone - t` 1 <br /> 6 TranSQptSeCl QPm�ppYzNamq rmr _,,I' U.S.EPA ID Number <br /> 7 Transporter Company Name U.S.EPA ID Number <br /> Ff <br /> 8.Designated Facility Name and Site Address q}f _ �.x� r M,.a U.S.EPA ID Number <br /> Facility's Phone: <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HIM and Padang Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> IL TrI <br /> z 2 O <br /> W <br /> f7 <br /> 3. <br /> 4. <br /> i <br /> 14. pecial Handling Instructions and Additional Information r^n. <br /> 014 r <br /> lb 7:1 <br /> r t rs 7, rr I, is .t.. -. •-p " .-.� - <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and aa inately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable internatim it and nabonal governmental regulations.If export shipment and I am the Primary <br /> Exporter,I candy that the contents of this consignment conform to the terms of the attached EPA Acknowledgment ofsent. <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 Rionat quantity generator)is true. <br /> GeneratordrTyped N Signature Month Day Year <br /> ±21 pikil <br /> y 16.1 temational Shipments v T PLJ 1 19 <br /> f— ❑Import to U.S. ❑Export from U.S. Po of entry/exit: <br /> ? Transporter signature(for exports only) Date leaving U.S.: <br /> tta 17.�ransporterAcknowledgment of Receipt of Materials <br /> Tre Wer Pdrged(fyped N Signatu Month Day Year <br /> a l`I <br /> b✓� <br /> Z T r2 P' dfrypedN - ICIr <br /> Q 9 Mon Day Year <br /> r <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quanti <br /> ty ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> I <br /> Manifest efemom Numher <br /> IUD.Ntemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL Facility's Phone: <br /> QW 18c.Signature of Ntemate Fadlity(or Generator) <br /> a Month Day Year <br /> z <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> O 1' 2. 3. <br /> 4. <br /> 1 20 Designated Facility Owner or Operator:Cenficefion of receipt of hazardous materials covered by the manifest except as nosed in Item 18a <br /> Printed/typed Name <br /> OWZ7Z_ Signature ` Month Day Year <br /> EPA Form 8700-22 Rev.12-10 Previous editions are obsolete. Z <br /> a1 L <br /> t f :•. DESIGNATEO FACWfY TO EPA's e-MANIFEST SYST M <br /> _. , . --— <br />