COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

Dln nl nr hrno /Corm desinned fo ion on elite 119-nitrM tvnewdter.l Form Approved. OMB No. 2050-0039 EPA Form 8700-22 (RO. 3-05) Previous editions re obsolete: _ =�- f T ED FACiiiTY TO GENERATOR S1 ATE (IF REQUIRED) v.�� .,�� ...,., � UNIFORM HAZARDOUS ......... ...... ... _..._ 1. Generator ID Number 2. Page 1 of 3 Emergency Response Phone 4. Manifest Traclang Number �` � (° y 0 � � JJ K.� WASTE MANIFEST _ � % �° ,r �l 5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) rf T?P�..j s7 L Ft_ Hi, 7t20W, �'•.i ti• i 'r. . 3 -7A-7 ,43rd_ tirte; - Generators Phone: r` "x= > ' 1c' U.S. EPA ID Number 6. Transporter 1 Company Name 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Sitee Address U.S. EPA ID Number '✓1�l :Iii ?^�•l�y��1��.1p%T''. �.��' AD 0 .^ .y. 0 '33r_'1 .6- a Facdib/s Phone: ga 9b. U.S. DOT Description (including Pro r Shipping Name, Hazard Class, ID Number, 10 Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (if any)) Quantity Wt /Vol. z 2. W C7 imc F I V rM 3. EB --1-8 20t4- 4. 4. NONMENTAL H* DEPARTMENT 14. Special Handling Instructions arid Additional Ii formation � #F �-x -17: � P"W -AER 1! 1::# S-5 . ��i`f�� ;�9�?'ias(v�:Y r�� ice:-: CHEM3PE S�; 2-4-1-53a""?43 %^' F3�Zk.'=+'J.1fiF- ..> :cT.: Sf -5 ONAL ERA CODES . SB�:. . "ONE � 3':P"i�t?i�''`:^,'�.1�.�= :=E'��Y�:i§L °e" t�.l T=� , 15. GENERATOR'SIOFFEROR'S CERTIFICAT N: 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 coi signment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization staternei t identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a smell eva ltdgger�eralor) is true. Generalors(Offerors Prin lTyped Nana V Signature -� f -.--. � Month Day Year 'n a ) j"" ti _.r 16. International Shipmentst% ❑Import U.S. ❑ Export from U.S. Port of er�rylexit: _ Z Transporter signature (for exports ondy): -. Date learang U.S-* CC 17. Transporter Acknowledgment of Receipt of Mat rials i1,f e Transpoger 1 P 'ntedfTyped Name Signature {y Q Monte Day Year i f .. —� f' 1Z.• 11 V� Z Transporter 2 Prinledrfyped Name Signature Month Day Year t fr F 18. Discrepancy 18a. Discrepancy Indication Space ❑ Qu 6ty ❑ Type ❑ Residue ❑ Pertel Rejection ❑ Full Rejection Manifest Reference Number. 18b. Alternate Facility (or Generator) U.S. EPA ID Number J_ V tai Facility's Phone. W 18c. Signature of Altemate Facility (or Generator) Month Day Year ZZ y19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) � 20. Designated Facility Owner or Operator: Certifia tion of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22 (RO. 3-05) Previous editions re obsolete: _ =�- f T ED FACiiiTY TO GENERATOR S1 ATE (IF REQUIRED)