Laserfiche WebLink
rte'"se print or type.(Form designed for use on elite(12-pitch)typewl'iter.) <br /> Form Approved.t]M8 No 2Q50d3U39 <br /> UNIFORM HAZARnou5 I 1.Generator 1D Number 2 Page 1 of 3 Emergency Res;arst Phare 4.Manitest Tracking Number <br /> WASTE MANIFEST J J K <br /> 5.Ge eralcrs Name and Mailing Address Gene.atces S'te Addrm#it different than maTgg address' <br /> Gcnerawes Phone <br /> I ra:'Sponer 1 Compaiy Noma <br /> ' f � <br /> US EPA,DNumber <br /> 7.T-arsponer 2 Con•.panr Name US EPA rD Number <br /> 8 Designated Facr-ily Name and Site Address US EPA ID Number <br /> Faciliys Phone: <br /> 9a. 9b U S DOT Descripticn i inciucring Proper Srpprrig Name.Hazard Class,ID Number, <br /> HAt and Patting Group'if any'. 10 Confiners i t Total 12.Unit <br /> No Type Quantity wt Viol <br /> 13 Waste Codes <br /> 1. <br /> O <br /> tz z. <br /> c� <br /> 4. <br /> 14.Special Handling InsUactians and AdcKonal Information <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:f hereby dedara that the Contends of this consignment are fatty and accurately niescr�ed above by the proper supping rtarte,and are classified,paclnaged, <br /> marked and Iaberehat the <br /> conterded.and ares al respects br proper cotndtfon For transport according to applicable Infernatto W and national g mimentel regulations.H export shipment and I am the Primary <br /> Exporter,I rrer6fy that Iha contents of Ws consignment corforn to Uta terms of the attad>ed EPAAcknowledgmeni of C H=L <br /> I certify that the waste in imization statement identified in 40 CFR 262.27(a)(V I am a large quantity generator)or(b)(f I am a small quantity generator)is true. <br /> Generator'"erors PrintedlTyped Name Signature Month Day Year <br /> —r Iii lntematicriWSh:pments <br /> F ❑Imporl to U S ❑F_xport from U.S. Pen of entryfexit: <br /> z Trarsperier signature(for exports onty): Date lea"U,S. <br /> W "is a sxrler kxnaw!edgnent of Receipt of Ma erials <br /> `WsXr.-'Pnn ecTypel Name <br /> 5tgrah;rr Manch Day Year <br /> U) <br /> Q Transporter 2 PrinledrTyped Name Signature <br /> Month Day Year <br /> 18 Discrepancy <br /> 18a.Disaeparcy Indication Space ❑ Quantity ❑Type ❑Residua ❑Partial Rejection ❑Full Rejection <br /> 185 Al:ema!a Faa6ty;or Generator; Mars fest Reference Number. <br /> US EPA ID Numbe <br /> V <br /> F Fac;fiys Phore <br /> Lu t8c 5fgnalure of Aiternate Facikq,or GeneratDrI <br /> Q Month Day Year <br /> U) 19.hazardous Waste Report Management Method Codes(ie.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1 2 3 4. <br /> Zu.Designated Facsity Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in hem 1 Be <br /> Paned typed Name Signature Month Day Year <br /> ?PA Form 8700-22(Rev 3.05) Previous editions are obsolete, <br /> IJ•1`41t:iFtA�Efl FAC1f-.lxy ff! C,�•"��HR�{7F <br />