Laserfiche WebLink
p type.( 1.Generat on elite(12 pitch)typewriter.) Form Approved.ON1B No.2050-0039 <br /> UNIFORM HAZARDOUS or ID Number 2.Page 1 of 3,Emergency Response Phone 4.Manifest 7racidng Number <br /> Please print or e. Form designed for use <br /> WASTE MANIFESTAi <br /> i '®t <br /> 3j s.;? �J <br /> 5,Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> t {f t y } o <br /> t�Liisi t� Ilii i �$�L4..y ..3 <br /> Generator's Phon-Nj"i" i I <br /> 6.Transporter 1 Company Name <br /> ;r lt;r U.S.EPA ID Number <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> 8.Designated.Fagility Name apd Site Address <br /> U.S.EPA ID Number <br /> Facility's Phone: t t <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers <br /> HM and Packing Group(if any)) 11.Total 12.Unit 13.Waste Codes <br /> 1 i'tr,l +ti,'' ;� ,:,rri;f"'t r• . ''t t. ;. No. Type Quantity Wt.Nol, <br /> w 2' <br /> 3. <br /> 4. <br /> 14.Spacial Handling Instructions and Additional information <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 EPAAcknowiedgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)orb if I am a small ua(i <br /> O( q "rJ ty generator)is true. <br /> Gen oto s/Offerol s Printed/Typed Name ! nature) r <br /> Mono Day Year <br /> ! <br /> y. ✓ <br /> 16,international Shipments <br /> Importto U.S. ❑Export from U,S, s Port of entry/exi <br /> Z Transporter signature(for exports only): 4 Date leaving U,S.: <br /> LU 17.Transporterftnowled�ment of Receipt of Materials <br /> TransporerPd/Tped,ame0 ..J , ! <br /> gnature <br /> dpn)h Day Year <br /> O. r5 a (�V�,`���'S J, -f' ,,,-•+N�f s` 3{3y°�'�: Y ,� ��r')J° . _ <br /> Z <br /> Transporter 2 Printed/ <br /> Typed Name (" <br /> y cow <,. r'' <br /> "._Signature' <br /> j`Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection 1 ❑Full Rejection <br /> 18b,Alternate Facility(or Generator) Manifest Reference Number: <br /> =r U.S.EPA ID Number <br /> U <br /> 1. Facility's Phone: <br /> w 18c,Signature of Alternate Facility(or Generator) <br /> Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU <br /> 4. <br /> �'' ! •�,. r 2. 3. <br /> 20.Designated Fadlity Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature <br /> - t Sit <br /> f' a Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete, <br /> TRANSPORTER'S COPS' <br />