Laserfiche WebLink
dW <br /> pn�t or type:(Form.designed for use on el• (12-pitch)typewrites) <br /> . ;n;:,. ii; Form Approved.OMB No.2050-0039 <br /> UI QRN HAfZARDQUS 1•Generator fDNumber 2 Ffage 1 TrackingiJumbar. <br /> 1NAUE"'MIFEST f ; j ,, ... �� ;►� 4 Q JJK <br /> 5"Generamrs Ndme aridlAaltirg Site Address(If di(feoar t Mian hiai8ng adrSs) <br /> Generators Phone. <br /> 6.Tianrporterl"CompariyName 13.S.EPA IDNumber <br /> '' <br /> 77 <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number' <br /> 8.Designated Facility Name and She Address ,r i y. U.S.EPA ID Number <br /> Fad( e:phon , <br /> ga' tib.U.S.DOT Description(including Proper Sh Aping Name,Hazard(lass,ID Number, 10.Containers ii.Tobe 12.Unit <br /> HM` atd Packing Gmup(d any)) No- Type Quantity WtNoI. U.IAfas6o Codes <br /> � 1 <br /> 2. <br /> r <br /> 4. 1 <br /> 14.._ Instructions and- <br /> 17 ;< i <br /> 15. GENERATOR'SKWMOR'S CERTIFICATION:I hereby dedam trot die contents of His consignment are fulty and.aa uraiely described above by the Koper shipping name,and are classified,packaged, <br /> marked and Iabeledfplacarded,and are in at n properoortditimtr transport according to applicable international and natronai governmental regulations.t export shipment and I am the Primary <br /> Exporter,I certify VW the contents of this eonsg erd conform to the terms of the attached EPAAdmowledgment of t;onseX <br /> t•t&rtfy mat tie waste minimization siaienien�in 40 CFR 26227(a)(d i am a large Quantity gendator)or(b)(dI amB+ige1 rM!a1> ftenerator)is he. <br /> GenaiatoeslO)femes Pnrrted/iyped ma Signature Monti Day Year <br /> ,. <br /> 16 tra>al s �. <br /> .Import to U. , ❑Export from Lf. Port oFe ry/exff <br /> Tflorter signature(for exports only): - Date leaving U.S:: .. <br /> W 17.Yta�Acknowledgmerd of Receipt of Materials ' <br /> Transporter l Primednyped Name Signature Monti Day Year <br /> 10 <br /> QTransporter 2 PrintedlTyped Name Signature blain Day f Year. <br /> H <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space Quantty ❑Type ❑Residue ❑Partial Rejection ❑FUN P49ciDn <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> ti FadBlys Phone: <br /> LU 18c.Signature of Ahemate Faai y(or Generator) tAoi Mi Day Year <br /> Z <br /> 19.Hazardous Waste Report Management Method (i.e codes for hazardous waste treatment disposal.and recycling systems) <br /> G 1, 2, 3. ji-7— <br /> . <br /> 20.Designated Facility Owner or Operator.Celt6catonlof receipt of hazardous materials covered by the manifest except as nded in Rem 18a <br /> PrintedfTyped Name 4Signature j Month, Day Year <br /> ' l e <br /> E' <br /> EPA Form 8700-22(Rev.3=05) Pre*us editions are obsolete. GENERATOR'S INITIAL COPY <br />