CORRESPONDENCE_2007 - Laserfiche WebLink

Home Browse Search

Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 7". Emergency Response Phone 4.Man'rfes4 Tracking Number WASTE MANIFEST f, x�f f ) fB i 0021 2"430 JJK 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) )fDl)P"0411;e11o:ck l,,'L V.4.. 1`-4C`'.. E ,'.`Di >'$:i 'a` )7',. ( Generator's Phone: ,t 2 6.Transporter 1 Company Name_ U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated gFacility Name and Site Address U.S.EPA ID Number 'Q i CAd*,,,kvittr,`i4�:= F 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('d any)) No. Type Quantity Wt.Nol. CK 1' (9 1 Iw'i' (if 441F ' z 2. w 3. 4. 14.Special Handling Instructions and Additional Information Wf"'m i?4,ova t'i't wlhktlp 141110hrip, to i 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 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(f I am a small quantity generator)is true. Generator's/Offeror's Printed/Typed Name Signature Month Day Year 2A I� �wt $ ° s y g JY• + J 16.International Shipments I— ❑Import to U.S. ❑Export from U.S. Port of entry/exit: z Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year ZZ Transporter 2 Printed/Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ° ❑Type El Residue ❑Partial Rejection El Full Rejection i Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J 47 Facility's Phone: h18c.Signature of Alternate Facility(or Generator) Month Day Year R IZ N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) C3 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 Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL Y