CO0047329 - Laserfiche WebLink

Home Browse Search

i Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number ��pp 2..Page 1 of 3.Emergency Respon�se�Pyhone 4.Manifest Track`in' JN�umber �+ WASTE MANIFEST cAll "7' d z1 D 003 ( `t a C7 G B F 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) nf:�'=J- I?- Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number+ tea^ 7.T porter Company Name ` �]'t U.S/J�p�%A�,ID Num( i nNumber 4 O V1,. VY� 8.Desated Facili Name and Site Address U.S.EPA ID Number CW-O 4CI90 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. 2. j w u.W...... _-..._.. t j t 3. .. j I 4. 1 1 14.Sial Holing Instructions and Additional Int mation 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are y and ac)1a a 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 appl' le internatiod national goverrmental 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 EPAAckn ledgmenl of CoI. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity nerator)or(b)(ia s all quantify generator)Is tale. nat Month Day Year j Genera sl0ffero's n drTyp d arri y� S �l . lernational Shipments El Import to U.S. El Export from .S, ort of entry/exit: Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Si nature Month Day Year Or t a ), ��tL ` J � Sign Month Day Year j Z otter 2 Printed/Typed Name 6l 1 t- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type u Residue ❑Partial Rejection ❑Full Rejection Manifest Reference NumW., 1Bb.Altemate Facility(or Generator} U.S.EPA ID Number J U tui Facility's Phone: 18c.Signature oiNlernate Facilify(or Generator) Month Day Year d Z illi 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) — I I H HEALTH LIJ ,. 2. 3. PARTMENT • / r i 20.Designated Facility,2wneror Operator:Certification of receipt of hazardous materials covered by the manifest exc t as ed in Ite 1 Prmled/Type arae Signator Month Day Year i 24 i � EPA Form 8700-22rev.3-05) Prev ous editions are obsolete. j DESIGNATED FACILITY TO DESTINATION STATE(EF REQUIRED)