UAR/PROP 65 - Laserfiche WebLink

Home Browse Search

Please print or type.(Form designed for use on elite(12-pitc,/ ypewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number \ WASTE MANIFEST Iva`r~ 000238771 JJ K � C��:7 Z � t,G• V�1•�S v 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) T'Ah v,tt5i Xtk 1C' T +Nc. vv. SAc1L1>w1c ,TD C-A. A`�by► LA,T As:-, c-A . A57-,7 Generator's Phone: Oillia - 154 1- 6.Transporter 1 Company Name U.S.EPA ID Number N�c + 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number C-R-a-m � 0,4 t JLT O►.( tri c, kb3c `v4 \ATS C,.�,Ap 2Y11-I(X�e^��t %- r\t1, C-%43 Facility's Phone: ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt./Vol. 1. ��t0A JAJAVV0 wA5,Tt � r Z 2. 3. 4. 14.Special Handling Instructions and Additional Information U5� rf?6Pr C p`fP 50,4 A(, rLore-c.7-tuc r YK1 SaS/r- oJA,- 3i3 2-a36 PP--F,L4F1;:�-- s� 142_x, . nlP L =rpt T A l 5C iiLe5 i.'ti c- t c,c n c 0 I N - 0 ,A q ,U 1. 15. GENERATOR'SIOFFEROR'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, 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement Identified In 40 CFR 262.27(x)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator'slOfferor's Printed/Typed Name Signature Month Day Year 16.International Shipments ❑Import to U.S. ❑Export from U.S. Part of entry/exit: Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/typed Name Signature Month Day Year O a J- Z Transporter 2 Printed/Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity El Type EJ Residue ❑Partial Rejection 71 Full Rejection r Manifest Reference Number: C 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U ra Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z h19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) UJI G 1. 2. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 188 Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. ISE IGNATl D 17-fACILITY TO DESTINATION STATE (IF REQUIRED)