COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

Please print or type.(Form designed for use on elite 12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 11.Generator ID Number 2.Page 1 of 1 3.Emergency Response Phare 4.Manifest{Trooking Number WASTE MANIFEST V V iJ 197621 M Y Y 5.Generator's Names and Mailing Address Gereratoes Site Address('d different than mailing address) d . Generator's Pte: 8.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 Facflity's Phone: ga, 9b.U.S.D0T Descrlptor(including ProperShipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Cafes HM and Padding Group(d any)) No. Type Quantity Wt.Nol. c � � 1 c1°a 3 1 VIA-- 4. . as 14.Special Handling Instructions and Additional Information 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that Ste contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeledfplacarded,and are in all respects in pts cottdidon for transport according to applicable nterrationaland national governmental regulations.It export shipment and I am the Primary Exporter,I certify that the contents of this consignment oonforrn to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 282.27(a)(d I am a large quantity gator)or(b)(If I am a small quantity generator)is true. GererstorsrOffera's PfinledrTypecl Nacre Signature Month Day Year 16.Indemational Shonerh Import to U.S. ❑Export from U.S. Pat of entrylexit: Transporter signature(for exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials Tramporter 1 PdrdedlTyped.Name Signature Month Day Year rn I- Q Transporter 2 Pdnted/Typed Name Signature Month Day Year or F 18.Discrepancy 1 Ba.Discrepancy Indication Space ❑ Quantity ❑Type 0 Residue Ll partial Rejebon ❑FWI Rejection Manifest Reference Number. 18b.ABemate Facility(or Generator) U.S.EPA ID Number U W Facility's Bane: 1 18c.Signature of Alternate Facility(or Generator) Month Day Year Vj19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) Uj 1. 2. 3. 4. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as rated in hem 18a Nntad/Typed Name Signature Nlonth Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete, GENERATOR'S INITIAL COPY