COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

a � 1 Please print or (ype. Form designedfor use on stile (12-pitch) typewriter.) Form Approved. OMB No. 20500039 .i. Generator ID Number c 2 Page i of 3 Emer ency Response Phone 4 Manifest Tracking Number FUNIFORM HAZARDOUS {, A (, Uti ). e �., ) , _ . r4- 9.+f1U " 3 k WASTE MANIFEST `1 lY - - fyp ' ? �!s JJK3 5. Genetglp�� N 4 •a��1N(a)INg (?rsbsxrf'It 6;()ft f'Af�1Y Generators Site Address (it different than mailing address) i ,f 17 f) 1i > ( i 141 Fat g1fta(_- f Generalors Phone: g 6. Transporter 1 Vmip nY Yt�e : � - U.S. EgAJ? )7 {l J 7 It1 s QUNiCnr",•,4lfhf uSidt'dt4S . 7. Transporter 2 Company Name ` U.S,.EPA ID Number '. 8. Designat d Facility Name and Site Address U.S. EPA ID Number II { ( .t1i +'✓ 1 `fClti`Tf3N 11' 4: , 1 .; ntttll ( I wnl'� AVr,III) I? Ftz:. ; Gti A3jfl CA1) 09 030 q 93 Facility's Phone: ( 4 "C1Y277 '1p7Qf1 9a. 96: U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12, Unit6 HM and Packing Group (if any)) ' No. Type Quantity WLNe' 13. Waste Codes 1 l .OV t't!'( 7H 11fi4l iFYlUf9tft3 WA.Tk'. , 8OIllo { r°,i +ks4^; PAi1:H) 3Q y z 2 t at E .op3± 715y Fe'.sT"C?>';'k'i ... F't. T't:^ e34?�.4;�•Q4> :i-` rr i'tYi:'"fi}_' r �'� t7 3. - 4. 14: Special Handling Instructions and Additional Information f`lr�l i,t `IVYN.G1' (, hot? Yv1TP'EC J, . Yr/ 7-2FS!� 3x011 NFiFhI.rM 91?'2 _ 11 f '' ('F2tTF71 .P t+ 3rd l. ' t .�y a?H 11riNttl. I At34. htfB(2 of Y `>01.. IDS Nf>CYO0004 ,'15C3t$ ^' P,PI 't)OPHIAYYI llttll ElGl (1ff (Ay0f 'Aftf3t /r r1 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 Ibis consignment conform to the terms of the attached EPAAcknowledgment of Consent I codify that the waste minimization statement identifed In 40 CFR 262.27(x) (if I am a large quantity generator) or (b) (If I am a small quantity generator) is true. GenefatorslOfferors Pinball ame Siynglure Month Day , , Year - �. t el 16. International Shipments zElimport to U.S. ❑ Export Som U.S. Pod of ent try/exi Transporter signature (for exports only): Dale leaving U.S.: V4 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Prnted/Typed+Name Signature Month Day Year cl� r' r� �l .f ! 1, f "•1 . 0 ` 'rr _ 1. t 7 . { . (,r< � % QTransporter 2 PdntedlTy ,ad Name / Signature Month Day Year 18. Discrepancy - Ills. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue _❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 181h. Alternate Facility (or Generator) U.S. EPA ID Number . J U µ Facility's Phone: w 18c. Signature ofAlternale Facility (or Generator) - Month Day Year a z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) L 2. 20 Designated Facility Owner or Operator. Codification of receipt of hazardous materials covered by the manifest except as noted in Item 18a - Pnnled(ryped Nam - 7 Signature Month Day Year !/� �/ • L. . eft l `"!. ;7 >e,v+ ,9'�•' ,� / i { i' i /, EPA Form 8700-22 (Rev. 3.05) Previous editions are obsolete, - TRANSPORTER'S COPY