Laserfiche WebLink
Please print or type. <br /> Form Approved. OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number =Pagegency Response Phone 4ifest Tracking Number <br /> WASTE MANIFEST 021321844 JJ <br /> 5. Generators Name and Mailing Address Generator's Site Address (if different than mailing address) <br /> Generator's Phone <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> 7. Transporter 2 Company Name <br /> U.S. EPA ID Number <br /> 8, Designated Facility Name and Site Address U.S. EPA ID Number <br /> - f - - . <br /> Facility's Phone::, �., <a: <br /> 9a_ 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12. Unit <br /> HM and Packing Group (if any)) No. Type Quantity 2. Unit 13. Waste Codes <br /> 1 pI <br /> 2. <br /> UJ <br /> 3. IL <br /> 4. <br /> 14, Special Handling Instructions and Additional Information <br /> ILI <br /> 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, <br /> 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 <br /> Exporter, I certify that the contents of this consignment conform to the terms of the allached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (ffl am a small quantity generator) is true. <br /> Generator's/Offeror's Printed/Typed Name Signature <br /> h � Month Day Year <br /> J 16. International IIIw Shipments <br /> ❑ Import to U.S. ❑ Export from U.S. Port of entrylexit: <br /> Transporter signature (for exports only): Date leaving U.S.: <br /> M 17. Transporter Acknowledgment of Receipt of MaterialsLU <br /> Transporter 1 Printe ped Name J Signaturey,� " v_ Month Day Year <br /> '� g <br /> 2e Transporter ped Name Signature <br /> Month Day Year <br /> t- <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space Quantity ❑ Type <br /> ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> 18b. Alternate Facility (or Generator) =4 I <br /> U.S. EPA ID N <br /> v .f <br /> Facility's Phone: <br /> Pru <br /> 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> ,Z <br /> 19. Hazardous Waste Report Management Method Codes (I.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> i� 1 • 2. 3. <br /> 4. <br /> 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. 0Ez81 MA E ED FACILI'll Y TO EPA 's <br /> P„MAN,FES T CSYSTES0 <br />