Laserfiche WebLink
1.ase print or type.(Farm designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> of 3,Emergency Number <br /> 1.Generator ID Number o <br /> UNIFORM HAZARDOUS <br /> WASTE MANIFEST <br /> 5.Generator's Name and Mailing Address Generator s Site Address(if different than mailing address) ru 4, ELE <br /> Generators Phone: U.S.EPA ID Number <br /> 6.Tranwpo—ner. CoT I a <br /> ,�aqy Nam <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> U.S;EPA D Number <br /> B.Designated Facility Name and Site Addressi <br /> U J <br /> j <br /> Facility's Phone: <br /> 7 9a. T9b.7U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> . Quantity Wtivol. <br /> HM and Packing Group(if any)) No. Type <br /> J. <br /> Cr. 0 <br /> 0 <br /> Z 2. <br /> 0 <br /> ? <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and—Additional Information <br /> :,Z <br /> iM <br /> 75. 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, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national goverrimental regulations.Ifexport shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached 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)(if I am a small quantity generator)is true. <br /> Signature Month Day Year <br /> Gerilzrator's/ era a 11 'r <br /> 25-01 <br /> 7 12 <br /> -1-6.lblemational ShipmentsImport to U.S. Exp❑ ort from U.S. Port of entry/exit <br /> Transporter signature for exports only): Date leaving U.S.: <br /> W <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter I-Printed[Typed Naple gignature Month Day ear <br /> 0 1 -7 L�-Z I <br /> Month Day Year <br /> Z Tra—nipoKi 2 Printedrryped Name I-Signat0re <br /> I18.Discrepancy ❑Type EIP.rtlal Rejection El Full Rejection18a.Discrepancy Indication Space El Quantity El Residue <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Facts 's Phone: <br /> w 18c.Signe Month Day Year <br /> Signature of Alternate Facility(or Generator) <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(I.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. <br /> L 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as rioted in Item 18a <br /> tedfTyped Name a!yre Month Day <br /> y. . Year <br /> P L <br /> EPA Fbr in 8700-22(Rev..3-D5) Previous dditidns irebbsolete.77. L <br /> DESIGNATED FACI L'I*TGENERATOR <br />