COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number c WASTE MANIFEST A. I 7 U 0 .3 i 7 :'• t 1 i t"!':1 f+1£•-i0 i'r 001" 520.147 Vw 5.Generator's Name and Mailing Address n .13I�2�:AIC3L trxA}`$ Generator's Site Address(if different than mailing address) ❑1ii<<T �:li i1=�':J�Ci7�Itt 1?iC. }:•1S{.lA-Trr ;Lid vTc _r701f,CA Generators Phone: ?DU 1F1--;syr 6.Transporter 1 Company Name U.S.EPA ID Number YB;DL -'c T-rt`rL',UC','d 13+:-C)TI01114r i+f i r is V e; 1 - .5 _. 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number l��-iL7,o:.ES'L•L�vt%'�%..`.ni.S==IS:t73'i<:?�:. L L.+01. Facility'sPhone: Ct.'i iG P? :I3tat3�D,l`_. 'xarb! r, n 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)) No. Type Quantity Wt.Nol. 13.Waste Codes 1' lrltii LS•'}��4 .{iLFJ, :EP7 'TI fI'I -:2 O w z 2. w c� 3. 4. 14.Special Handling Instructions and Additional Information FtS`ervixi`:mer..h_dby VSST3 -j- t_'-m:ruc-t,r•-tzirc-'(! ;zrru[-_+,•ra�lwN! W-fici w;;kv...nr on :>r1:13�fxt:;C i0 dz'd r:•'-3bet]!r3'l.hJ il`1•?TJ �7.Yc:i9�c:li:!:+: _ .�_ •?Y�;L,....::1[_� .I. 1';V:''._��?70?�::'�I- 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 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 Ihal 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. Generalo5j�OHerors PrintedfTyped Name Signature D✓' Month Day Year } 16.International Shipments l ❑Import to U.S. ❑Export from U.S. Port of entry/exit: i ? Transporter signature(for exports only): Dale leaving U.S.: rr 17.Transposer Acknowledgment of Receipt of Materials Trapsporter1Pfinted.'Typed;Name Signature / Month Day Year O - z Transporter PrintedfTyped Name^ '�_ Signature \. Month Day Year F-• 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑ 1 Residue Partial Re'eclion Full Rejection Manifest Reference Number: r 18b.Alternate Facility(or Generator) U.S.EPA ID Number F. J U u- Faci!ilys Phone: LQ 18c.Signature of Allemate Facility(or Generator) Month Day Year z O 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1 2, 3. 4. 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 Farm 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY