COMPLIANCE INFO_2020 - Laserfiche WebLink

Home Browse Search

Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4,ManirestTracking Number WASTE MANIFEST C/Q�U�30'��7 ;L( Rif "— ]1 t 'Gg JJK 5.Generator's Name and Mailing Address 6yt a-00 3 Generator's Site Address(if different than mailing address) Po6of: [JAC) C&,-fel-",y si -kk,4 C4 Genera is Phone: 6.Transporter 1 Company Name U.S.EPA ID Number G� IiV 1-0iwr CSG 7U� 7.Tr sporter 2 Comp y Name U.S.EPA ID Number Z I L�{ 8.Designated Facility Name and Site Address U.S.EPA ID Number p (rfIcility' one: 9a 91b.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.Nol. w o x N��.N C l u�ro(.� ��,l, S,V, '7Q•4r s W u r P1 f K4--s4-d��n; Z 2. w 3. 4. 14.Special Handling Instructions and Additional Information Fk6t f71 17-1vvtC'e �tvcv0 Y vse 0-•10✓&s -Us-��1�r 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, 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 EPA Acknowledgment 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)(ifI ani a small quantity generator)is true. Generators/Offeror's Pnnted/Typed ameSign ure "— Month Day Year 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit: _ ? Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials LU ►— Transporter 1 nted/Typed Name Signature Ix / /% Month Day Year CL Cn Z Tra po ter 2 Printed Typed Name Signature Motnth Day Ye r � � I , � rte► 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number U LL Facility's Phone: 0 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 1. 12. 3. 4. 1 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedlTyped ^ / Signature Month Day Year t�V�� , (-) V EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DE TED FACILITY TO EPA's e-MANIFEST SYSTEM