COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

Please print or type. (Form designed for use on elite (12-1 typewriter.) Form Approved. OMB No. 2050-0039 UNIFORM HAZARDOUS 1 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST FLE 5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) Generator's Phone: 6. Transporter i Company Name U.S. EPA ID Number 7. Transporter Company Name U.S. EPA ID Number S.Designated Facility Name and Site Address U.S. EPA ID Number US Pn .PiD% 51$ iJYWy ' 1>1ie.5 J E$�2tr9 LHt' ?+Ri Facility's Phone: - San 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 Wf.Nol. f. 0 _ QO ' K w Z 2. U.1 t7 3. 4. 14 Specal HandlingInstructions and Additional InformationCI, f t 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 EPAAcknowledgment 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. Generator's/Offerors Printed/Typed Name bignature Month Day Year 16. International Shipments _ ❑ Imponto U.S. ❑ Export from U.S. Port of entry/exit: Trans orter signature for exports only): Date leaving U.S.: W 17. Transporter Acknowledgment of Receipt of Materials Transported Printed/Typed Name Signature Month ay ear O a _ aTransponer2 Printedlfyped Name Signature - -'---- Month Day Year 18. Discrepancy 18a, Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U,S. EPA ID Number ZiU Q LL Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year a Z a—i 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 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 PrintedrTyped Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY