Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.P77 . <br /> ency Response Phone 4.Manifes <br /> t Tracking Number <br /> WASTE MANIFEST . . ' ' 013 313 6 7 JJ K <br /> 5.Generatorsl! andMailing Address Generator's Site AddressVdifferentthanmailingaddress) <br /> Generator's Phone: <br /> B.Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Desi�rrsntpd Facility,Name and Site Address U.S.EPA ID Number <br /> Yii:.. ..�t.:.r. :•�•. <br /> Facilit)rs Phone: <br /> ga 9b.U.S.DOT Descrip1on(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> F ._/r.� <br /> Z 2. <br /> w <br /> c� <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information Ijo- "r'= >: ° / •.. i t i <br /> 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, <br /> marked and Iabaled/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 <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAckncwfedgment of Consent. <br /> I certify that the waste minimization statement Identified In 40 CFR 262.27(a)(41 am a large quantity generator)or(b)(f I am a small quantity generator)is true. <br /> Generators/Offerors Printed/Typed Name Signature Month Day Year <br /> f Al :1 ? <br /> —j 116.International Shipments ❑E port from U.S. Port of en !ex t: <br /> P- ❑Import to U.S. try <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> t2 Transporter 1 Printed/Typed Name Signature Month Day Year <br /> O <br /> CL <br /> rn <br /> Za Transporter 2 Printedffyped Name Signature Month Day Year <br /> H <br /> 1 B.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity, ❑Type ❑Residue ❑Partial Rejection ❑Ful Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> uQ FacilirVs Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> m19.Hazardous Waste Report Management Method Codes(is.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Uj C 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item Ill <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />