COJFGLFE5 - 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 (A 60�IR -1-180 � i(SoO S: 3 - 1 q0d 019703745 JJ K 5.Generator's Name and Mailin,g Address Generalor's Site Address(if different than mailing address) E o,S EnP a %a&-6 q0t we,* 3.-00.6 (g54o 5. ,4„;n 2d 14, ,C-C-V% nd, vA 23 z'St5 Generator's Phone: 0 A� w 1000 (�. CA 6. sporler 1 Co pang Name U.S.EPA ID Number 'Va�ok 6AD05--3'6(nCo7,14 7.Tra iter 2 Coijpany Name U.S.EP ID Number >��gna�tedyFa ilk ity Ndhe and S�Address U.S.EPA ID Number jt��(►1oq��c., 1'l�hi3 Facility's Phone: S(pz) Al?,- 5.4 5' 16AD 42`3 4 o°Io l°I ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. �ht beo�r l'r.2x�s G,(w 3eo� DM I oo 'P Z 2. w 3. 4. 14.Special Handling Instructions and Additional Infnrmatinn 1 1 W 5 ' `✓ 'P?r- W � t _"'�J J 06 to 15. GENERATOR'SlOFFEROR'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 labeledlplacarded,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 EPAAcknowiedgment 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/Offeroes Printed/Typed Name �7 Signal Month Day Year d .o M�5 6-K?M LtruS Fjro'aa, fix- 10 10 ZED 16.International 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 oTransporte;A-ly'nted/Typed Name Signa Month Day Year CL I© I� Z Transporter P)/I, itedffyped Name Signature Month Day Year Vii- �1 �.c'�5 �-i-� L , L. 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 Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z 2 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 O erator:Certification of receipt of hazardous materials covered by the manifest except as ncted in lem 18a Printed/Typed Name Signatures A Month Day Year EPA Form 700-22 Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM