COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 7.Generator ID Number2.Page 1 o/ 3.Emergency Response Phone 4.Manifest Trucking Number �+ WASTE MANIFEST �� Q V U 0. J„'c% C- VES 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) Generators Phone: l=I V E D 6.Transporter 1 Company Name U.S.EPAID Number 7,Transporter 2 Company Name U.S.EPA ID Number e.Designated Facility Name and Site Address NC41TU niIDTkICAIT .S.EPA ID Number Fadliys Phone: 9a. 91p.U.S.DOT Description(including Proper Shipping Name.Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13,Waste Codes HM and Packing Group(if any)) No, Type Quantity M./Val. L., QO K Iz 2.1 -. O 3. 4. 14.Special Handling Instructions and Additional Information --- 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 Iabeledlplacarded,and are in all mspects 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 tens of the attached EPAAckremiedgment of Consent. I certify that the waste minimization statement identified in 40 CFR 261(d I am a large quantity generator)or(b)(if I am a small quantity g rata)is true. GenemtorslOfferors Printed/Typed Name Signature j Month Day Year —11 16.International Shipments F 11 Import to U.S. ❑Export from U.S. Pon of enbylext: = Transporter signature(for exports only): Dale leaving U.S.: W 17.TransporterAcknoMReceipt edgmenl of of Materials K Transporter 1 Printed/Typed Name Signature Month Day Year Z Transporter 2 Printedfryped Name SignaWre, Month Day Year 7 t18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: W 18c.Signature of Alternate Facility for Generator) Month Day Year 6 2 o19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 1. 2. 3. 4. 20.Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manAgnaWre esl except as noted In Item i8a 1 PrintedRyped Name Month Day Year i {-� EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR