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 C - �' (.l� .i .+ �,, `} '�a # ia,rrt 1 � a , ", Ju 1% t1a 1 5.Generator's Name and Mailing Address (r tt 'r u§ Generator s Site Address(if different than mailing address) gg ( ! r �`�`''�+ �r�fft'�� Generators Phone: 6.Transpoor 1 Company Name U.S.EPA ID Number, )d'n' ��.�` �•^i✓'��'/"F 7�"it" �.a``r,r��,'(�;�1,',� f '�.� ,�� ,rrr. 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Addresse r r; 3g {{ pp U.S.EPA ID Number t/ .. pp d Facility's Phone: r .y�l r.-� s .��+l� �` F ,�'^� ° .�.,Y.,.� �� tia 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./Vol. �-' 1 2. C7 3. 4. 14.Special Handling Instructions and Additional Information i 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 1 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[am a small quantity generator)is true. Generatoes/Offerors Pnntedfr ped Name 4 Signature. Month Day Year j 16.International Shipments t r__ ❑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 Transporter 1 PrintedfTyped Name Signature p.` Month Day Year a z Transporter 2 PrintedlTyped Name l Signature Month Day Year H 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity El Type El Residue El Partial Rejection El Full Rejection Manifest Reference Number: >_ 18b.Alternate Facility(or Generator) U.S.EPA ID Number IIJ ti LL Facility's Phone: UJ 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 05 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) ® 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.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY