Laserfiche WebLink
Please print or type. Form designed for use on elite (12-pitch) typewriter.) <br /> <br />Form Approved. OMB No. 2050-0039 <br />A <br />ce c) ......F- <br />ne w z t.0 0 <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Nun._ c O 6'3 1 14 .3y I t <br />C"N"e-'ZT1:3'.',41-1--7,-4q- <br />2. Page 1 of <br />i <br />3. Emergency Response Phone <br />goo (9tq 91.3G <br />4. Manifest Tracking Number <br />018486279 JJK <br />Generators Name and Mailing Address < I - Generator's Site Address (if different than mailing address) <br />L.., c"). ft el (Au MO i un oil exArckY.P.5 "1‘.--5 <,1,4,-(.4.11--,-/-4-1-15- - <br />6[7.-._) -S.t..4 t.Z‘ • rtil r3-46740-6-7-4o5-444e--21- L se `\‘-• %.• • Ar-s-,--AAA ,--1 V-1) • <br />gtO SSS 6 7&'? GA Generator's Phone: - <br />Transporter 1 Company Name U.S. EPA ID Number <br />P Cti"r i CA- 9,4‘vt\rtres. fritedliol Senri'e-re'S I cA- os386 <br />Transwrter 2 Conwany <br />CinCaletfr <br />Name U.S. EPA ID Number <br />et OVa b vk , Lvk c I CAA ();- Cqaq 6 1 el <br />Designated Facility Nsitse <br />Facility's Phone: <br />and Site Address C.4..us b,d c 0 v_(c4,01) U.S. EPA ID Number <br />1, 6,g0 (-0 <br />1-..0 e-4.4.-k cA 'YO 12 I CJA.' 0, a.) 8 go 9 (9 i 9 <br />ga. 9b. U.S. DOT Description (induding Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes HMand Packing Group (if any)) No. Type Quantity Wt.Nol. <br />Nov\ (44.A 14-m-c,4ovs 0) cis4G, $0 tt'd c -.-- <br />I Dvk 1 00 <br /> <br /> <br /> <br />.--I <br />14. Special Handling Instructions and Additional Information <br />3-* I I- 2-1 - 005-26. PO I.) /00S-022 <br />61,604(3 <br />15. GENERATOR'S/OFFEROR'S CERTIFICATION: I 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 lam 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 lam a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Generators/Offerors Printed/Typed Name Signature . Month Day Year <br />1,l4-- 144.4.--145 ti co..) 1 080 Stlieit;r2le.e" 1 10 I.5- la 1 <br />.._. <br />g <br />r-LII 16. International Shipments LIII Import to U.S. Export from U.S. Port of entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: TRANSPORTER 17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 PrintedfTyped Name Signature/)Month <br />Mor-I-Lstw,,..) i <br />Day Year <br />/q,t....--- 1 lo IS I.2i <br />Transporter tedfTyped Nam@ <br />91.-- C1.11 <br />Signatur Month Day Year <br />TittA (SA,-e 1 n, I /6 1 (3 1)1 4--- DESIGNATED FACILITY --0- 18. Discrepancy <br />Discrepancy Indication Space [1111_ Quantity Type 11 Residue Partial Rejection Full Rejection <br />Manifest Reference Number: <br />Alternate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone: I <br />Signature of Alternate Facility (or Generator) Month Day Year <br />I 1 <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. .. 2. 3. 4. <br />20. Designaac;Iner or Operator Certification of receipt of zardous materials covered by the manifest except as nded in Item 18a <br />Printed/Typed Name <br />k_fi, it(i/uA <br />Si t gnaure . . Month Day Year <br />1--f--_._.- I r 94------ - I / 0 iri2-1 <br />EPA Form 8700-22 (Rev. 4i53 Previous editions are obsolete. DESIGNATED AöILlTYTO DESTINATION STATE (IF REQUIRED)