Laserfiche WebLink
red for use on elite (12-pitch)yewriter.) <br />1. Generator ID Number 12. <br />W <br />ASTEOANIFEST I <br />5. Generator Name and Mailing Address <br />Generators Phone: <br />6. Transporter 1 Company Name <br />7. Transporter 2 Company Name <br />Page 1 of 13. Emergency Response Phone <br />Generators Site Address (if different than <br />t t <br />Facility's Phone: <br />9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />HM and Packing Group (if any)) <br />QQ <br />CC <br />1-%.f-5--4 <br />Uj5 .....t•�-} {. `^,r ^t ^-{ "r`..�`.Ftw�r* <br />Form <br />address) <br />U.S. EPA ID Number <br />U.S. EPA ID Number <br />10. Containers_ 11. Total 12. Unit <br />No. Type Quantity Wt.Nol. <br />OMB No. 2050-0039 <br />4 <br />13. Waste Codes <br />r�§ t r+f�f�t ' 3wtlst'rq,�`�§rtt'tt111 <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 certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment 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 quantity generator) is true. <br />3er}eratorslOfferors Printed/Typed Name ipaiture Month Days Year. <br />16. temational tihipmants <br />❑ Import to U.S. ❑Export from U.S. Port le a leaving <br />U.S <br />Transporter signature (for exports only): Date leaving U.S.: <br />17. Transporter Acknowledgment of Receipt of Materials <br />l ransp .OXA-P+'intedlTyped Name ¢' Signature Month ear <br />n Day Y: <br />Sian I ture Month Day Year <br />18. Discrepancy <br />18a. Discrepancy Indication Space El Quantity ❑ Typ. <br />18b. Alternate Facility (or Generator) <br />J td, <br />V <br />iQ Facility's Phone: <br />18c. Signature of Alternate Facility (or Generator) <br />0 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, <br />UJ 1, 2. <br />❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />U.S. EPA ID Number <br />1 <br />and recycling <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />PrintedlTyped Name Signature <br />1 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. <br />4. <br />GENERATOR'S INITIAL COPY <br />