Laserfiche WebLink
0 i <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS <br /> 1.Generator ID Number 2.Page 1 of 3.Ems rncy Response Phone 4.Manifest Tracking Number <br /> SKS <br /> WASTE MANIFEST V v <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Generator's Phone: U.S.EPA ID Number <br /> 6.Transporter l Company Name <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facility's Phone' <br /> ga 91b.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 WtNol. <br /> Z 2. <br /> w <br /> 3. j <br /> ( <br /> 4. 1 <br /> 14.Special Handling Instructions and Additional Information <br /> 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, <br /> 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 <br /> Exporter,I ceNity that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> 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 quanfity generator)is true, <br /> GeneratoeslOgerars PbntedlTyped Name Signature Month Day —Year <br /> =3 16.International Shipments <br /> I— ❑Import to U.S. ❑Export from US. Part of entry/exit: <br /> Transporter signature(for export only): Dale leaving U.B.: <br /> 17.Transport Acknowledgment of Receipt of Materials <br /> K Transporter 1 PrintedrTyped Name Signature Month Day Year <br /> aF <br /> Transporter 2 Printed/Typed Name SignatureMonth Day Year <br /> K <br /> r <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Perial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone'. <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i ii codes for hazardous waste Vestment,disposal,and recycling systems) <br /> 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 /> 1 Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />