Laserfiche WebLink
�I! Please print or type.(Form designed for use on elite(12-pitch)typewriter.) <br />! UNIFORM HAZARDOUS r Generator 10 Nun berF­A;, AAB 111,2' <br /> G <br /> 2,Page 1 0l 3 L r y resr,uise <br /> WASTE MANIFEST Phyne„ �. imit"t7mokin9 N " �f <br /> : (�+ <br /> N 0 5 7 2 LI C V J <br /> S Gnne'ale•v ani+ inn Af r ling Addrecs Generator's <br /> "aa—ass hl deferent than maNin9 add—) a'n <br /> Ger—IcursPhone NIFEST <br /> 6.Transpprtar I Company Name U i EPA 1.N-meet <br /> 'iransponBr 2 Company Name U.S EPA ID Number <br /> S.Dasignalad Facility Mame and Sde Adtlmss U.S EPA to Number <br /> 16` <br /> \O'RT• <br /> 0.eQ�AM <br /> Facih 's Phone: <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers it.Total 12 Una 13 Waste Codes <br /> HM and Pecking Group(if any)) No. Type 0...My <br /> 1 <br /> O <br /> r— <br /> a <br /> w <br /> z <br /> w <br /> O <br /> ai <br /> II 14.Special Handling InSfin ions and Additional Information t <br /> OA <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 dassified,packaged. - t, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.It export shipment and 1 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)(if I am a large quantity generator)or(b)(it l am a small quantity generator)is true. <br /> Generator's/Offeror's Printed?yped Name Signature Month Day Year <br /> EMER <br /> J 16.international Shipments <br /> r ❑Import to U.S. ❑Export from U.S. Port of entrylexil: <br /> Transporter signature(for exports only): Date leaving U.S <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter I PrintedlTyped Name Signature Month Day Year <br /> � O <br /> � AC <br /> ( Q Transporter2PrinledlTypedName Signature Month Day Year <br /> 18 Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ QuaNdy I❑Type ❑Residue ❑Penial Rejection ❑Full Rejection <br /> { <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> ILL Facility's Phone: <br /> 118c.Signature ofAltemate Facility(or Generator) Month Day Year 1 <br /> t <br /> a I. <br /> rnz ,( <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. <br /> 2. 13. 4. 1 <br /> 9a <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> II OnnfcrlrTme�i Ale„+e 3 <br /> 7v��'•� I Signature IMonin I Day 'YearLl I <br /> 1 <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> 4 <br />