COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

'i Please print or type. Form Approved.OMB No,2050-0039 1.Generator ID Number 2.Page 1 of 3,Emergency Response Phone 4,Manifest Tracking Number UNIFORM HAZARDOUS , � ��; t 0, 7 Z5JJK WASTE MANIFEST 5.Generator's Name and Mailing Address . Generator's Site Address(if different than mailing address) 3-'T"1MM,CA WKIM Generator's Phone: 8.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site AddresspAGhcl(, �F�V f `E=1 � f�`i` U.S.EPA ID Number 3f -A&T iuICO fA11). t ANW2624s Facility's Phone: ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13,Waste Codes HM and Packing Group(it any)) No. Type Quantity Wt.lvol. O w - i w i 3. 4. 14.Special.Handling Insiructions and Additional Information 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 labeledlplacarded,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 Exporter,l certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Copsent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(11 am a small quantity generator)is true. GeneralorslOfferor's PrintedlTyped Name Signature T Month Day. Year J 16.International Shipments t— ❑Import to U.S. ❑Export from U.S. Port of entrylexit Z Transporter signature(for exports only): Date leaving U.S.: LU 17.TransporterAcknawledgment of Receipt of Malcrials Transported Printed/Typed Name Signature Month Day Year CL Z Transporter 2 Printed/Typed Name Signature Month Day Year t-- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residuei ❑Partial Rejection ❑Full Rejection Manifest Reference Number:18b.Alternate Facility(or Generator) U.S.EPA 10 Number J U Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z S219.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU 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 PdntedlTyped Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY