Laserfiche WebLink
Oun, LG 09 11 : 43a Jeff Kindorf 2098207818 P. 5 <br /> Please print or typo.(Form designed for use on elite(12-pitch)typewriter.) <br /> Form Approved.OMS No.2050-0039 <br /> 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Ntu fi �� <br /> UNIFORM HAZARDOUS ^ �.' <br /> WASTE MANIFEST ' A.� 1-3 <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Generator's Phone: <br /> U.S.EPA ID Number <br /> 6.Transporter 1 Company Name <br /> U.S.EPAiO Number <br /> 7.Transporter 2 Company Name <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facility's Phone: <br /> 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> ga' No. Type Quantity Wt.Nol. <br /> HM and Packing Group(if any)) <br /> t. <br /> rY <br /> O <br /> LLI <br /> w 2 <br /> O 1 <br /> i I <br /> 3. <br /> I -f <br /> 4, j <br /> t <br /> I ' <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 labelediplacarded.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 EPA Acknowledgment of Consent. <br /> 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 /> Signature Month Day Year <br /> GeneratoeslOfferor's PrintedrTyped Name _.- <br /> -1 16.international Shipments171 import to U.S. ❑Export from U.S. Port of entrylexit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> a 17.Transporter Acknowledgment of Receipt of Materials <br /> '&� Transporter 1 PrintedlTyped Name Signature Month Day Year <br /> O <br /> a <br /> Q <br /> Month Day Year <br /> Transporter Printedrryped Name Signature <br /> tY <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space quantity ❑Type ❑Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number. <br /> U.S.EPA ID Number <br /> r 18b.Alternate Facility(or Generator) <br /> J <br /> U <br /> u- Facility's Phone: Month Day Year <br /> 188.Signature of Alternate Facility(or Generator) <br /> a <br /> Z <br /> CD19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 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 Month Day Year <br /> PnntedrTyped Name Signature <br /> EPAFDrm 8700-22(Rev.3-05) Previous editions are obsolete. GE6'ERP\TC:?'S[ME i CGhi` <br />