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 C A R 0 0 0 2 8 5 9 3 2 1 88&641-3940 019759532 JJ K 5.Generator'_Name and Mailing Address Generator's Site Address(If different than mailing address) C.CSF DepaFhMrt of Kill FNakh Tess TIVOtIMM Fadlky 1390 Market St STE 210 9000 W.1Mmalia Rd San Franebw CA 94102 Thary CA 95377 Generator's Phone: 41 5 2 52 - 3 9 7 15 6.Transporter 1 Company Name U.S.EPA ID Number FAviro ylleftl Lo9isfimr IncC A R 0 0 0 2 1 7 5 1 3 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number HSZM@t NIC. 6300 Soman Dtt Kontos Clly MO 64129 Facility's Phone: 816 924-5984 IMOD981123391 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)) 13.Waste Codes No. Type Quantity Wt.Nol. 1 X • ' 2.N� D r�i97�11��s c�9�s1tt S�Lf� �� , a J-L 3 4 14.Special Handling Instructions and Additional Information %Z—t4mvi 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 toim¢ 'on statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(KI am a small qu ntigenerator)is true. GeneraloeslOffer r n yped me Signature t Month Day Year "' 0, ' 16.Intemational Shipments F ❑Import to U.S. ❑Export from U.S. Port of entry/exit: ? Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Q Transporter t ri m Signature 1 Month Day Year Z Transporter 2P le hyped ame Signatu Month Day Year a t- 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_ 0 LL Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 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. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM