COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

Please print or type.(Form designed for use on elite(12-pitch)*nter) Form Approved.OMB No.2050.0039 UNIFORM HAZARDOUS 1•Generator ID Number 2.Page 1 of I Response Phone 4.Manifest Tracking Number WASTE MANIFEST 001M�1_299 JJ ..,. 5.Generator's Name and Mailing Address Generator's Site Address(d different than rrWW 9 address) Generators Phone: 6.Transporter 1 Company Name y U.S.EP _P)_S r � S 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address «. 1.n U.S.EPA ID Number Facillty's Phone: "9 ._ . fs ga• 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Cases HM and Packing Group(d any)) No. Type Quantity Wt.Noi. a 2. W t7 3. 4. 14.Spial Handling Instructions and Additional Information w, 15. GENERATOR'S/OFFEROR'S CERTIFI.PATION: I hereby declare that the contents of this consignment are Aft and accurately described above bythii proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper gaxTdion for transport according to applicable international and national governmental regulations.U export shipment and I am the Primary Exporter,I certify that the contents of this crosigmmerd cordbw4o the temr`s of the attached EPAAclawMedgment of Consent I certify that She waste minimization statement identified in 40 CFR 262.27(a)(di am a large quantity generator)or(b)(•d I am a small quantity generator)is true. Generabw's/0((erors Printed/1 yped Name Signature Month Day.- Year _J 16.International Shipments I- ❑import to U.S. ❑Export from U.S. Port of entrylexit z Transporter signature(for exports only): Date leaving U.S.: W 17.TranspaterAcknowledgment of Receipt of Materials �2 Transporter 1,PdnWffyped Name Signature lunch Day Year O CL rn Z Transporter 2 Printed/Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Fhb Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number J 0 Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year 4 Z F) 19.Hazardous Waste Report Management Method Cates(.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 1. 2. 3. 4. 20.Designated Facility Owner or Operates Cerdfiption of receipt of hazardous materials covered by the manifest except t as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COP`(