CORRESPONDENCE_2007 - Laserfiche WebLink

Home Browse Search

le2e print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST { { a ";«g {°j ' 5.Generators Name and Mailin Address Genera)ors Si Ad�Iress(if different than mailing address) k{?##rsr ay;,a g°a3i.�aa'r�pp gg pp §§ q toPH # ,lpt e6flR 64;: 1 ` '11 "(W)&- ® -yi Al Nil 11,.it Generator's Phone: x I 4.i"f *H", , 6.Transporter 1 Company Name U.S.EPA ID Number ra J, ,. 7.Transporter 2 Company Name l U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number 'AT;iga4 `88 k'.a 'i##tbstt a ;f.°e, . t' t,4'4.' '� Facility's Phone: 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt.Nol. 1' ?'fl �4t1 e�ttt�t- Q0 N,0 8,. sg f 4N. r ' f'§`9 Of, 1f19 f'f f, OIXMt l ' Z 2. LU 0 3. 4. 14.Special Handling Instructions and Additional Information 7 °. �•ts€f'�tc!�:€ 'd�f ,')t�.�ta �i�araa�ft�t�? tttr-1ta9. 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)(If I am a small quantity generator)is true. Ge era tors/Offergrs Printed/Typed Name rt Signature Month Day Year - 111 o POW, k -+ 16.Intemationai Shipments z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporief1 Printedfryped Name° ' Signature Month Day Year QTransporter 2 Printed/Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space El Quantity ° ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection i Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number J V S Facility's Phone: LO 18c.signature of Alternate Facility(or Generator) Month Day Year Z 65 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LLI 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 Pdntedrryped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY $j g