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.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) %JL-1 V Ef j V1- H, P�\,e tl-oGrr" LOS JUL 3 1 2M �1 cp Generator's Phone: r zc-A 6.Transporter I Company Name U.S.EPA ID Number INC. ..EWRONMENTALHEALlH T.Transporter 2 Company Name U.S.EPA ID Number AL 8.Designated Facility Name and-Site Address C-30 W 17TH ST--LONG BEACH, CA lo J Facility's Phone: 9a. 9b.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 Wt.Nol. 1. UN 1950,WASTE AEROSOLS FL4MW43LE (EACH 1,11K),F 0 EXCEEDING IL CAPACiTY)l 2-1 ULI Z 2. LLI HE R 3. -TERET-4CED w.ANTE, WAS-FTCE1VFD.K%N r)U D ANI)-511 RED Y,)R UPSEQtm G;,REUSE c-ptos E,y C V,,TTn-,, X-r 01 Fsrlp ri T7 0RANTED Te'j-, trir. -s 14. -y- L.M i W 1971 J"0Cl- "r j'�" -�.,FH A '!7S1EF-kL AND SI*, PEGUL�,IIGNS, 4-7ZOSBI, 4. PM UJW7S TO ACCEPT THE RE1VtENC&) & k')VElMN1LAS ALL )F WAS AND ALL ACMRDINGLY AS BEEN NA N)La 14.Special Handling Instructions and Additional Information ------- -2 USE APPROPRIATE FPIIE� BOL ER G 126 A- 15. GENERATORVOFFEROR'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 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/Offeror's Printed/Typed Name Signature Month Day Year, -1 16.International Shipments Import to U.S. ElExport from U.S. Port of entry/exit: I.- Z Transporter signature(for exports only): Date leaving U.S.: W17.Transporter Acknowledgment of Receipt Of Materials W Transporter 1 Printed/Typed Name Signature .:i Month Day_ Year :2 0 0- M Transporter 2 Printed/Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ElPartial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number tai Facility's Phone: W18c.Signature of Alternate Facility(or Generator) Month Day Year !;R Z 0 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LLJ1. 1 r 2. 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 SignatureDay Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR