Laserfiche WebLink
Please print or type.(Form designed for use on elite(12- pewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number <br /> =2PageTo13.Erneen Res nse Phone 4.Mantfest Trackin NumberWASTE MANIFEST C,AL(t_'sE;1 PO, - 12 @ � 1 001985037 g (� C <br /> 5.Generators Name and Mailing Address FORWARD, ALd Generator's Site Address(if different than mailing address) `d u 1 <br /> t 9C- 9 S AUS 16N RD. <br /> _. :A, X33 <br /> 269-962..4 T <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> SHOP HAZARDS SOLUTIONS,INC CAD 000648i97 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> r._,.,. <br /> ' 8.Designated Facility Name and Site Address <br /> GEhi-RAhCH DOVA LL;,}_ U.S.EPA ID Number <br /> 11865'• TE ROCK,RD, <br /> R CHO"DRE)OV , 95742 <br /> Facility's Phone:916-351-0,%D <br /> 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> 1 No. Type Quantity Wt.Nol. <br /> rr s t s s'r{ ktM 1-iA,ZAJ-'iT.--G91S,xA TE S01 <br /> ® <br /> ABSORESENTI CART S 01 1 -"'� 215 : <br /> W <br /> Z 2. <br /> W <br /> C9 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> r ���t�.t�i�^�;"+a°+t��.2��91-ga s.°^ c��`". <br /> a`A-F7`?'A.YY'3`AT E PPOTE$ 87q. 4.LS�T¢;y`!S;• <br /> ERG 171 <br /> 15. GENERATOR'SlOFFEROR'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 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)9r-(b'f(�<am a small quantity ggerator)is true. <br /> G erafor s/Offeror Prin ed(Typed Name �/ Signature Month Day Year <br /> ,/ <br /> .J 16.International Shipments <br /> ❑Import to U.S. > ❑Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving.U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed(fyped'Name Signature Month Day Year <br /> QTransporter 2 Printed/Typed Name Signature Month Day Year <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type <br /> ❑Residue ❑Partial Rejection ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number. U.S.EPA ID Number <br /> GEN! has the appropriate <br /> LL Facility's Phone: permits for, and will a0kt <br /> W 18c.SignatureofAlternate Facility(or Generator) the waste this generator IS Month Day Year <br /> Z `J <br /> rn19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and <br /> W 1 2. <br /> 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 q 1 t/ Signature p gMonth Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. 9f <br /> DESIGNATED FACILITY TO GENERATOR <br />