COMPLIANCE INFO_2019 - 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.Manifest Tracking Number WASTE MANIFEST v , .� 643 V`' ES 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) DEBBIE KAJIGTAP.A.R9 Generator's Phone: 6.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 Facility's Phone: 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. •± f•..• •ea•H'YV_ S��w: `Y'£1..:.'M1.S..Pvt�9l•3 r,_�?.:?, t. la L 3. 4. iC44 n; A I?6,? � '''L'�.'ZTE Lr'"MD. ;'IIY cs TMI "' _ -a2::.�"�:..,. •..:..tis. �'�.i J� w..,:.._ -�� a ,a:� wtt , 14.Special Handling Instructions and Additional Information EF Tle ice t <tlt. ctedi A Y Va u70 .f 4..vn1Y3 t t I ?31L a; F"imeY'.$a t.lilrr s +r� 1 idwh i. o 2;liatO?s a9 aY2h 's J'a";Ul tY'Ca@ 3 ICiIY'tiC CX s G G !�^Yt "SII {trC 'tIl ; I o r r r, R .; Tr P r£`!' ..r ?1 , " sqr i! . a 7T ^rs . .�? s� * J r'"+. ;e C+ r ,nps r p'+ T� - L TSL.e 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,arca 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)(if I am a small quantity generator)is true. Generator's/Offeror's PrintedfTyped Name Signature Month Day Year ,j 16.International Shipments F ❑Import to U.S. ❑Export from U.S. Port of entry/exit: z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials LLI Transporter 1 Printed/Typed Name Signature amu"'" Month Day Year O rl _ r Z Transporter'2 Printeclrryped'Natne Signature Month Day Year H 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 J U Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 55 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 1. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY