COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

y A Nf 71 ifs03937,47.5 S'PPW Please print or type.(Form designed for use on elite(12-pitch)typewriter) Form Approved.OMB No.2050-0039 T UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 74—Manifest Tracking Number WASTE MANIFEST C' A L a U 0 2 B^4'6 2 111 � {,f 00)49�3 is 0097z) , �,j" 30`4 4 FLE 5.Genprato�'s Nae-aAd ili_ng.Address Generator's Site Address(if different than mailing address) 1'i,,q t1(o/�4�t +iS�TpCYit��aiS Miguel ,L' VV Vit.Airp at't Wry -staf*t0n,Cr ubwtr Generator's Phone: 0-00190244'4 6.Transporter 1 Company Name U.S.EPA ID Number t,.can HWbwM'5 Ffw41k4I1iet ral 1.jer4m.tnC_ MA D 0 3 9 2 2 7 5 0 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number CleRn I I asbers ATa tdite U.0 ararsttwdW UT 940219 Facility's Phone: (4351264-0100 9e, 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.Nol. 1 14AM77.FIAZ0.RN.31#SWA.M. ID,Wok;.. X2f1�,F _ 0018 ;�52 w M 2. w ca 3. a. ( 14.Special Handling Instructions and Additional Information 1_t k339 0 E .>71. 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, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.If export shipment and I am the Primary Exporter,I certify Utat the contents of this consignment conform to the terms of the attached EPAAcknowledgmentof Consent. " 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 small quantity generator)is true. Generator's/Offerees PrintedfTyped Name bignature ,>^ on ear ^r —t 16.International Shipments" F— ❑Import to U.S. ❑Export from U.S/ Port of entry/exit: K Transporter si nature for.ex orts only): Date leavingU.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Pdnted(ryped Name Signature Month Day Year IL QTransporter2 Printgd(ryped Name Signature Month Day_ Year 18.Discrepancy 18a.Discrepancy Indication Space El Quantity ❑Type El Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b,Alternate Facility(or Generator) U.S.EPA ID Number J CJ Q LL Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) H040 1 3. T- 20. Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY +.Paan t�arbcws hZ14 the tee and mil accgpt um wgctQ thl�Vftr4tm of,T'hiplPicR:.