COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

• Please print or type.(Form designed for use on elite(12-pitch)Rypewriter.) NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number WASTE MANIFEST ?2-2 Generator's Name and Mailing AddressM1 Generator's Site Address(if different than mailing address) i. Generators Phone:''A]19 1TI-V'd-'A i 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number 1, att'00, 3t:3��s 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)) No. Type Quantity Wt.Nol. 1. 7 9 _ . AZ I E . 4 5W t I O Z 2. W 0 3. 4. 3.Special Handling Instructions and Additional Information 14. GENERATOR'S CERTIFICATION: I certify the materials described above on this manifest are not subject to federal regulations for reporting proper disposal of Hazardous Waste. Generator'slOfferor's Printed/Typed Name Signature Month Day Year -J 15.International Shipments 0 Import to U.S ❑Export from U.S." Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: 16.Transporter Acknowledgment of Receipt of Materials W onth Day Year Transporter 1 PrintedlTyped Name Signature 0 131 1 10 f Si btMonth Day Year Z- Transporter 2 Printed/Typed Name 9u t- 17.Discrepancy 17a.Discrepancy Indication Space 0 Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 17b.Alternate Facility(or Generator) U.S.EPA ID Number J_ V Facility's Phone: w 17c.Signature of Alternate Facility(or Generator)' Month Day Year Q Z 18.Designated Facility Owner or Operator:Certification of receipt of materials covered by the manifest except as noted in Item 17a Printedrryped Name Signature Month Day Year 6-NHM-C-C-11 6-GENERATOR'S INITIAL COPY