COMPLIANCE INFO_2023 - 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 _JJ K 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generator's Phone: 6.Transporter 1 Company Name U.S,EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: 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. 1. Z 2 Uj 3. 1 4. E 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 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)(ill,am a small quantity geng(ator),is We. Generator'slOgeror's Printed/Typed Name +" Signature ; a Month Day Year J 16.International Shipments j.._ ❑Import to U.S. ❑Export from U.S. Port of entrylexit: _ Z Transporter signature(for exports only): Dale leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials �2 Transporter 1 Printed/Typed Name Signature Month Day Year n� Z Transporter 2 PrintedlTyped Name Signature Month Day Year 18.Discrepancy 18a,Discrepancy Indication Space ❑ Quantic ❑Residue ❑Full Quantity El ❑Partial Rejection Rejection Manifest Reference Number: 18b,Alternate Facility(or Generator) U.S.EPA ID Number U u- Facility's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year 4 z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) Ul 1. 2. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PnnledlTyped Name Signature _ Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY COy IF YOU RECEIVED THIS MANIFEST,YOU HAVE RESPONSIBILITIES UNDER THE e-MANIFEST ACT,SEE INSTRUCTIONS ON REVERSE SIDE.