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 9 Number WASTE MANIFEUi T V ES 5. Generator's Name and Mailing Address ADAIAW4 TN?O F�K. Generators Site Addreas (fdifferentthan mailing address) i Dp lk i)r ",FE 900 Generators Phone: 6. Transporter 1 Company Name U.S. EPA 10 Number 7. Transporter 2 Company Name U.S. EPA ID Number B. Designated Facility Name and Site Address ,.;UA ES la7WICAL SOI r 'My5 U.S. EPA ID Number r _l 112: t rIlill 1.L'1' A1RMT Rt; 11iiX FR', i + 44301Facility's Phone: 9a 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, M Number, 10. Containers 11 . Total 12. Unit HM and Packing Group (if any)) No. Type Quantity WtNo1. 13. Waste Codes fY QO C Z 2. w c� 3. 4. 14. Special Handling Instructions and Additional Information 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 EPAAcknoWedgment of Consent. I certify that the waste minimization statement identified in 40 CFR 26227(a) (if I am a large pull generator) or (b) (if I am a small quantity generator) is We. Generators/Offerors Printed/Typed Name Signature Month Day Year X n 16. International Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit = Transporter signature (for exports only): Date leaving U.S.: w 17. TransporterAcknowledgment of Receipt of Materials Transporter 1 P7int drryped Name Signature Month Day Year aTransporter2 PdntedlTyped Name Signature Month Day Year 10. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number. 18b. Aftemate Facility (or Generator) U.S. EPA ID Number J U LL Facility's Phone: 18c. Signature ofAltemate Facility (or Generator) Month Day Year Q z C7 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 1. 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as rated in Item 18a Printedlryped Name Signature Month Day Year EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY