Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Farm Approved.OMS No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator 10 Number 2.Pal 1 of 3.Emergency Response Phone 4.Manifest Trracking Number <br /> ((��[[y� �+ <br /> WASTE MANIFEST - --.1 U 0 U J 4 3 4 J 9 VES <br /> S.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name .S.EPA ID Number <br /> 7.Transporter 2 Company Name JUL 0 7 2015 U.S.EPA ID Number <br /> - <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> ENVIRONMENTAL <br /> HcArTW nrMPTUICNT <br /> FalsPhone. <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name.Hazard Class.ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any) NO. Type Quantity wt./Vol. <br /> a0 _ .. <br /> 4' <br /> Z Z. <br /> Liu <br /> O <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 15. GENERATOR'SIOFFEROW CERTIFICATION: I hereby declare that the contents of this card gnment are fully and accurately described above by the proper shipping name,and are deasified,packaged, <br /> marked and Iabea drplacarded,and are in all respects in proper condition for transport according to applicable intemationaland national governmental regulations.If export shipment and I am the Primary <br /> Exporter.I certi y that the contents of this consignment canform to the temre of Ibe attached EPA Acknowledgment of Consent. <br /> I cervi y that the waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quantity generator)an(b)(Mean a small quantity gambo r)is true. <br /> Generators/O9eror's PrinledlTyped Name <br /> M Month Day Year <br /> J 16.International Shipments' <br /> F ❑Import to U.S. El Export from U.S. Pon of entry/exit: <br /> = Transporter signature(for exports only(: Date leaving U.S. <br /> CK 17.TmnsporterAcknowledgmentaf Receiptof Materiels <br /> Transporter 1 Printedllyped Name Signal. Month Day Year <br /> O <br /> d <br /> Z Transpode,2 PrmtedRYped Name SgnaWre Montth. Day Year <br /> L- <br /> 18.Discrepancy <br /> i 18a.Discrepancy Indication SpaceElPartial Re ❑Full Re <br /> El Quantity 1:1 Type ❑Residue IecBon jedbn <br /> Manifest Re/Dente Number. <br /> laid.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> W <br /> Iso.Signature of Alternate Facility(or Generator( Month Day Year <br /> Q <br /> Z <br /> H19.Hazardous Waste Report Management Method Codes(ia.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> O 1. 2. 3. 4. <br /> [20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> rinbusTyped Name Signature Month Day Year <br /> EPA Form 8700-22( OT105) Previous editions are obsolete. DESIGNATED WCILiTYTOGENERATOR <br />