COMPLIANCE INFO_2015 - Laserfiche WebLink

Home Browse Search

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 5.Generator's Name and Mailing Address - Generator's Site Address(if different than mailing address) _ �A1`4TE17H CA~ r 2-09 SL-13 IDS,P, Generator's Phone: 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 -REV RD 0—I DGE, A7 Facility's Phone: c� r _ - ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit and Packing Group if an Quant' Wt.Nol. 13.Waste Codes HM ' 9 P(� Y)) No. Type rtY 1. 1 _ P0,041057, A ?E LIGHTERS, ^ 0 REQ#115 2 �'J �"�5�y` fdSi �Lh114�`` '1LEr s y n.S. , . 1, ( x001} ERG#126 3 lUNi9iBF WASTE PROFPI!#E, c. 1, tU';c 7 ! s t_ki; � (`\ D="' 14.Special Handling Instructions and Additional Information 1,11 22503a16LDR 2;. zi- ' 1�c :nA LA y 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 EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator's fferoes Printed/Typed Name Signature Month Day Year 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Z Transporter signature for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year QTransporter 2 Printed/Typed Name Signature _.iMonth Day Year t-- 18.DiscrepAncy 18a.Discrepancy Indication Space ❑ Quanfity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Q �- Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Z N19.Hazardous Wane Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as need in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are'obsolete. DESIGNATED FACILITY TO GENERATOR