COMPLIANCE INFO_2021 - Laserfiche WebLink

Home Browse Search

Please print or type. 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 d"; ;QJflfi '>;.'k:<e * ) r.. .t�� .Eki"r 197903 JJK 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) r�t`��'rAx. �• -;�a:s��:�1� ��T.tF'i°�:t�t?>;�. ��rcrr:�.°��a Generator's Phone: 1?--'s, tt•'?r f r A 1 6.Transporter 1 Company Name U.S.EPA ID Number !:f.r #i., INC I y 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number WX.. 915 i I °SI.Lf-`!i .dull of i4T'?i"t`f.T, P ..a_ W.1 5-!fi 1f5F:A"T-rf', Facility's Phone: ga. 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)) No. Type Quantity Wt.Nol. 13.Waste Codes 1. WAS-W-- C-ORP00,TVE L:T$,�O11), DA'S TC,, , r 0002 4lo.t. p _j5 5 . n . mI I? (SiIL?Ct)#t LU 2. MON 4'.IPA 11A1Ax14ra3'3!JS kJAS.17-, S�iIT..:iTTi (AY.F.> T:TFRI, i 3. 4. 14.Special Handling Instructions and Additional Information 31 O'Nf 4..#"77)0 '�} e�•jc.►�2H�tiss►_ �yi �za tt.aiti;�t: ,�ar�•o:i;:�. i:'k�.';t`��f.� l�?'i1"` Yf ACI Pi'l 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)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generators/Offerors PrintedlTyped Name Signature Month Day Year 16.International Shipments F- ❑Import to U.S. ❑Export from U.S. Port ofentry/exit: ? Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Tran gpprter 1 Printed/Typed Name Signature �i Month Day Year jETransporter 2 Printed/Typed Name Signature Month Day Year 9 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 J U LL Facility's Phone: C3 18c.Signature of Alternate Facility(or Generator) Month Day Year Q 11 Ay 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 Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY