COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

I Pleawpnnf erAy(�e.(Form designed for use on elite(I pitch typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS I 1.Gedneretor ID Numbar 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST t'' `f' ". " ,. JJ 5.Generator s Name and Mailing Address Generator's Site Address(if different than mailing address) Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number r.a�'1, tPPe,r ey:x Xm<P,-� ...{bi ai;t kwtS RirY 44'Ra✓4+.M� 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number 00'Inc. { 5,;2sS Facility's Phone: ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt.Noi. w 2 ,r. ��v' � awn r `��•{[�.'s• f`'J 9 M�..f LU 2. LU t9 3. 4. 14,S ,.pecial Handling Instructions and Additional Information 15. GENERATOR'S/OFFEROR'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 EPAAcknowledgment 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)(f I am a small quantity generator)is true. Generatoes/Offeroes Printedfryped Name Signature Month Day Year 16.Intemationai Shipments i— ❑Import to U.S. ❑Export from U.S. _ Port of entry/exit: Z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transp er 1 P6n Name-, nature /` Mfgig .. fth Day Year O �p r _. Z Transporter 2 Printed/Typed Name Signature < Month Day Year 1!- 18.Discrepancy 18a.Discrepancy Indication Space El Quantity ❑Type ElResidue ❑Partial Rejection El Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number " :J tfJ Facility's Phone: 18c.Signature of Alternate Facility(or Generator) Month Day Year Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G1. 2. 3. _as' 4, 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Be Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete, GENERATOR'S INITIAL COPY