HomeMy WebLinkAbout1620 e brundage _envirotech report 6.22.20_104-126M
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NON- HAZARDOUS 1. GereWor ID Number
WASTE MANIFEST
5. Generatods Name and Mailirg Address
Generator's Ftore:
6. Transporter t Company 1`19 ma -. .
2. Page 1 of 3. Emergency Response Phone 4. Waste Tracking dumber
1 E€#.- 56 -5 -0525
Ger.erator's-Sile AM,'ess (f different than r, aping addretss)
U.S. EPA ID Number
g'��'�►"- U.S. EPA 10 Num r
U U -M �
7. TransFo�e�2- C�offi Vvy Flame
8. Designated Facility Name arid Site Addrars U.S. EPA ID dumber
CSI (Coles--,- Inc!) M. k: Col c!; Enwxonn cnl;ft l
1620 E- hx-tmdagta I,,:iLnim
M !93307
Fac;i
s Pty: ��Y�J�jY
9. Wasta Shipping Name aid Description
10. Ccrdal ens
11. Total
Quantity
46&&
12. Unit
Wt.Nol.
v f.... r .- _ _ -
ttio.
Type
1' Hon Ham ardour. Va'" +-c Solid (Soil rioxingr)
Dale gAn U.S.,
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w16. Transporter Acknowledgment of Paceil t of k'aterials
2.
3.
4.
Month Day Yer
}- Tr2n`port:r i PrintecrlTypEd Name
a
Signatura
0
N
Q Transporter 2 FV10ediTyped Name
Signature
Month Cay Yea
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». Lpecai na tiny mbuc am-u tuti nww4l eri 11:1-11 1twIl
ij Soil rroxing : — Prof ilc1J.O i7 i2 —0 i —CS I
USE OSIII' , 2.PPRO T &"7?X= PRECsUTT -O 'tS
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^�d a� a`ass pied packaged,
14. GENERATOR'SIOFFEROR'S CERTIFICATION: i f erby declare that tr.e contents of this cor rnnent are fully ar:d accuratety deserved at: -are by the proper shi ing name, �, , P 9 ,
�� A ra s .rt according to a iicahle international and nationd governmental regulations.
marked 2nd labeled-'placarded, and are In a7 r- ^.1 in proper ccrd�t.on for I n p g pp
Generato?&'Of'ercf s Hnted/Typed Name Signature t4lanth Day Yea
y I
i5. lnt-;rnatknJ Schipm -nts ❑ Import to U.S.
❑ Expcgi from U.S. Pcrt at entr/l.xtL I
Trans rtcr Simalura for experts only):
Dale gAn U.S.,
k
--
w16. Transporter Acknowledgment of Paceil t of k'aterials
Month Day Yer
}- Tr2n`port:r i PrintecrlTypEd Name
a
Signatura
0
N
Q Transporter 2 FV10ediTyped Name
Signature
Month Cay Yea
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17. Discreparcj
17a. Discre arcy lndicatcn Space Quantity
❑
El T Yp e El Fes,due ❑ P2tti21 Rejection
❑ Fuli Re;ection
thnifesl Refererce Nunber:
U.S. EPA ID Number
} 17b. Alternate Facility (or Generator)
hJ
a
u- FacPit f s Phona:
Month Day Ye;
w 17c. Sigrature of Alternate Facility (or Generator)
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IYIi8. DESig-iated Faci5 y O,r,ner or Operator. Certif'cztion of receipt of mateda's covered by the manifest except as netad in Item 17a
Month Day Ye
Printedryped Name
Signatura
_
DESIG AT�D FACILITY ITY TO GENET ATE
11977 Rev. 9109
169 -BLC -0 5 ( )