COVEWFWP8 - Laserfiche WebLink

Home Browse Search

NON-HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Waste Tracking Number WASTE MANIFEST Generators Site Address(if different than mailing address) 5.Generators Name and Mailing Address Generators Phone: U.S.EPA ID Number 6.Transporter 1 Company Name U.S.EPA ID Number =L. 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address Facili 's Phone: } 10.Containers 11.Total 12.Unit g.Waste Shipping Name and Description No. Type Quantity wt/vol. O F- a Lu Lu 2. W to 3. 4. 13. Special Handling Instructions and Additional Information '7 1 omen are full and accurately described above by the proper shipping name,and are classified,packaged, 14.GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this con sig y p marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. Month Day Year Generatoes1011erors Phnte&7yped Name J 15.Intemational Shipments ❑Import to U.S. ❑Export from U.S. Port of entrylexd: Date leavi U.S.: z Trani rter Si nature for exports only): cc 16.Transporter Acknowledgment of Receipt of Materials Signature Month Day Year u,jTransporter 1 Printed/Typed Name O Month Day Year N ' '` Signature X Transporter P6ntedlTyped Name r cc 17.Discrepancy Indication Space ❑Residue ❑Partial Rejection Full Rejection 17a.Discrepancy ❑Quantity Type Manifest Reference Number: U.S.EPA ID Number Y 17b.Alternate Facility(or Generator) J QMonth Day Year LL Facili 's Phone: LOU 17c.Signature of Alternate Facility(or Generator) F a z c� W W D 1B.Designated Facility Owner or Operator.Cer6ficalion of receipt of materials covered by the manifest except a e ted in Item 17a � Day Yea Printed/Typed Name b. TRANSPORTER 01