Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1 Generator ID Number 2.Page 1 of 1 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST . u r'4 ;)�t`ffita1 0025U9JJ <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> v ,A; 5 <br /> Generator's Phone: - <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Of <br /> rets,'A Y'+ # ` A J1,Z: +& 9� <br /> Facility's Phone: <br /> 9a• 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> W 1' 10;,1 <br /> 0b na t t:i't i <br /> e°< <br /> 14 <br /> l >ta3 <br /> Z 2. <br /> W <br /> 0 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> .5#4,•'e¢,*:q YR.�tf 9,96 ,.,` t�b *V_I ,.ii3t^kf : $i „ ME:ta ` <br /> IAN <br /> ;R-- t. <br /> 4 <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 attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)('d I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generator's/Offeror•s Printedrryped Name Signature Month Day Year <br /> J 16.International Shipments <br /> H ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Ij Transporter 1 Printed/Typed Name Signature Month Day Year <br /> 0 <br /> �.IL <br /> �F <br /> Z Transporter 2 Printedrryped Name Signature Month Day Year <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quanti <br /> ty El Type El Residue El Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> ® 1. 2. 3. 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 /> PrintedlTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev;3-05) Previous editions are obsolete. GENERATOR'S INITIAL <br />