Laserfiche WebLink
Please print.or type (Form designed for use on elite(12-pitch}typewriter) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS I'-Generator ID Number = e Manifest Tracking Number <br /> 2.Page I of 3.Emergency Response Phon J030M6 B <br /> WASTE MANIFE5T JG <br /> F <br /> Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Generators Phone: <br /> 6 Transporter 1 Company Name U.S.EPA ID Number <br /> 7,Transporter 2 Company Name U.S.EPA 10 Number <br /> S.D"MNSlddress <br /> US EPA ID Number <br /> k;A <br /> 15,915 v tla Ro-'K Road <br /> *,4M1tbJ Lilq(IfY43,4,A ',X24.' <br /> Facility's Phone: <br /> ga 9b.U S.DOT Description(incluclung Proper Shipping Name,Hazard Ci3ss,ID Number, 10 Containers11 Total 12.Unit <br /> HM and Packing13.Waste Codes <br /> F_ <br /> Group(if ani Na Type Quantity wt.ivol, <br /> T)T-71 <br /> C <br /> 0 l (.0 <br /> 2. <br /> LU <br /> 3 <br /> 4 <br /> 14.Special Handling Instructions aril Additional Information <br /> r:-,i;)i q I C)M 40 TKAIMED 440•.•f: PP f—' <br /> df'+i !3395 395 ap';1#1"1 <br /> 15. GENERATOR'SIDFFEROR'S CERTIFICATION: I hereby declare that ft contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labelediplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental reguWicins.If export shipment and I am the Primary <br /> Exporter.I derilify that the contents of this consignment conform to the terms of[be attached EPA Acknowledgment of Consent. <br /> I cw%that the waste minurnization statement iderthfied in 40 CFR 262,27(a)(if I am a"quantity generator)or(b)(if I am a small quantity generator)is true. <br /> PrintedifTyped Name Signature Month Dal YTr <br /> -J 16.International Shipments <br /> Export F-1 import to U.S. from U.S. Part of enlfyjexlt: <br /> Z <br /> Transporter signature(for exports only): Date leaving U-5. <br /> IX17.TrainsporWAcknowledgment of Receipt of Materials <br /> LLI <br /> � Tr7rlef I Printeffyped Naft Month Day Year J <br /> 0 <br /> -J' <br /> U) <br /> X Transporter 2 PrintedfFyped Name Signature Month Day Year <br /> GG <br /> 18.Discrepancy <br /> laa.Discrepancy indication Space El Quantity F Type F]Residue E Parliai Rejection ❑Full Rejection <br /> Manifest Refererce Number <br /> 18b.AAemale Facility(or Generator) U.S EPA ID Number <br /> ria Facility's Phone: <br /> Uj C3 18e.Signature of Alternate Facility(or Generator) L Month Day Year <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i e.,codes for hazardous waste treatment,disposal,and recycing systems) <br /> 20.Designated Facility Owner or Operator Certification at receipt of hazardous materials covered by the manifest except as noted in item 18a <br /> Pnntgryped—Name Signature Mbnlh Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br />