Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch) pew iter) <br /> Form Approved,OMB No 2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFESTsf t ? >s !a <br /> -JJ <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> a <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 /> .;i t' <br /> Facility's Phone: i <br /> 9a. 9b,U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers, . 11:Total 12,Unit <br /> HM and Packing Group(if any)) No, Type Quantity Wt.Noi. 13:Waste Codes <br /> w 2. <br /> 3. <br /> �i <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> .r 7 3 <br /> cr y! <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 Conpnt4 <br /> I certify that the waste minimization statement Identified In 40 CFR 262.27(a)(if I am 6 large quantity generator)or(b)(if IAm a�mall quantity generator)Is true. <br /> Generatprs/Offerors Printeded Narqe J Srgnatura <br /> Yp ffill <br /> Monthy Day Y <br /> �✓ j Year <br /> —+ 16.International Shipments gg <br /> F— <br /> El import to�U.S. �U.0 <br /> Z ❑Export from U.S. Porto;en <br /> Transporter signature(for exports only): r Datq eavi <br /> LU 17.TranspoderAcknowledgment of Receipt of Materials <br /> Transporter 1 P,rinted/Typed Name <br /> Signature ^jj J 1� Month Day Year <br /> QTransporter 2 Printed/Typed Name <br /> Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection 1 ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) <br /> J U.S.EPA ID Number <br /> V <br /> Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 77� <br /> 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 /> i5 nted/Typed Name - Signature r <br /> Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> TRANSPORTER'S COPY <br />