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 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST °pyt f ¢ °fig 82460 JJK 5.Generators Name and Mailing Address Genere ors Si e A ress(if different than mailing address) ssiho:%1P"n3n Iws cg a4 ' t salts' €um"' '.Awk NIS 0`4-ul" < llf-1k €1 1 it)I A- I 'I 1n)16 S ° t Generator's Phone: a.," 6.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 Address U.S.EPA ID Number 'A A,FM(k�`I?0 1 -09-44,g.:9 r)1 Facility's Phone: 9a. 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(if any)) No. Type Quantity Wt.Nol. M, WOIan. `t 1.aa�,aRB Kitt 'ki )l,.3119) Z 2. W 3. 4. 14.Special Handling instructions and Additional Information Islay : A a)(',"002X({ <` 6 '��. / I'It"" ra11` l 061 'ad s )'('1�, wfitiall tholdhily, Utw°;t tt 15. GENERATOR'S/OFFEROR'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,l 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/Offeroes Printed/Typed Name Signature Month Day Year s, 'x 16.International Shipments If h ❑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 J2 Transporter 1 Printed/Typed Name Signature Month Day Year C co .. . Z Transporter 2 Printed/Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑ResiduePartial Rejection ❑Full Rejection ❑ Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number =.r WV f facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year H R I CD I 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) ® 1. 2. 3. 4. ! n ed Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a d Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY