CORRVAMV1 (2) - Laserfiche WebLink

Home Browse Search

Please print or type. II II III II II III II Form Approved. OMB No. 2350-0039 ERATOR o- I UNIFORM HAZARDOUS WASTE MANIFEST I. Generator ID Number 2. Page 1 of 3 Eme.ge .cy Response Phone 4. Manifest 015097176 Tracking Number FLE Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) Generators Phone: I Transporter 1 Company Name , U.S. EPA ID Number I 7 Transporter 2 Company Name U.S. EPA ID Number I 8. Designated Facility Name and Site Address U S EPA ID Number , Facility's Phone: I oa Pb. U.S DOT Description jinclulng Proper Sripp41:1 Name Hazard Class, ID Number, 10. Containers It Total 12. Unit 13. Waste Codas HM and Packir,g Group (if aryl; No Type Quantity VVt.iVoi. 1. .4 GENE 2. 3. 4 14 Special Handling instructions and Additional Information ' i GENERATOR'SIOFFEROR'S CERTIFICATION: l hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, aid are classified, packaged marked and labelediplacarded, and are in al' respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I ant the Primary Exporter, I certify that the contents of this consignment conform to the terms of me attached EPA Ackiewledgment of Consent, I certify that the waste minimization statement identified in 40 CFR 262.27im if I am a large quantity generator) or (b) (ill are a small quantity generator) is true. GeneraTors:Offero?s Panted/Typed Name Sgnature Month Day Year _.1 1— International Shipments l'.._ _i rr.pici to l., 1; 0 Export from U.S. Port of entry/exit: Transporter signature (for exports oily Date leaving WS.: TRANSPORTER 17 Transporter Ackno.,Vedgment of Recept of Matra 5 Transporter 1 PrinteliTyped Name Sgriature Month Day Year I III Transporter 2 Printed/Typed Name SIna,....re Month Day Ye,..1- I I I I 4----- DESIGNATED FACILITY --0- it. Discrepancy its Discrepancy Indication Space Ei Quantity il Type 17 Residue Partial Rejection Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number Facility's Phone: I I 3c. Signature of Alternate Facility (or Generator) Month Day Year I I 13. Hazardous Waste Report Management Method Codes (i.e.. codes for hazardous waste treatmeni disposal, and recycling systems) 1 2 3. .. 23 Desrgnated Facility Owner Of Operator: Certification of receipt of hazardous materials covered by the marifest except as r cr.e:, ^ ':el- laa Printed/Typed Name Signature Month Day Year I I I I EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY