COMPLIANCE INFO_2019 - 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 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST J J K 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) 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 HM and Packing Group(if any)) 13.Waste Codes - No. Type Quantity Wt.Nol. " O ! w z 2. w O 3. 4. t 14 Special Handling Instructions and Additional Information ,I'I'��.,_� {C •�� i'-d •-Zr SIF �` ¢�: � B1� .�j'�-.� �,.....� ,.Jtf� /��.�i��J. -'?,. ' ' E!"i;s Sift=r ELf� TPAINC--; AN t"1..3 t3. 'F9�t e,fEt# PIPE 15. 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, 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)lift am a small quantity generator)is true. GeneratoesrlOfferoes Printedrryped Name Signature 9 Month Day Year J 16.International Shipments H ❑Import to U.S. ❑Export from U.S. Port of entry/exit: K Transporter signature(for exports only): Date leaving U.S.: LW 17.Transporter Acknowledgment of Receipt of Materials 0 Transporter 1 Printed/Typed Name Signature f /r 9 Month. Day, Year IL EGr ..� '�'3;r.X1,2_5, -....". ; z¢ Transporter 2'PrintedrrypedName Signature Month Day Year W 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 V LL Facility's Phone: LU 18c.Signature of Alternate Facility(or Generator) Month Day Year a ' z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU D 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 Printedrryped Name Signature Month Day Year EPA Form 8700-22(Rev.3175) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR STATE(IF REQUIRED)