COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

imprint or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 iINIFORM HAZARDOUS 1.Generator ID Number 2.Peg e 1 of 3.Emergency Response Phone 4.mandest TracMing Nurobw �[ WASTE MANIFEST 002006 "750 J J K 5.Generaloes Name and Mailing Address Generators Site Address(Kdifferent than mailing address) Generator's Phone: 8.Transporter 1 Company Name U.S.EPA 0 Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Facili s Phone: ga 9b.U.S.DOT Description{including Proper Shipping Name,Hazard Class,ID Number, 10 Certainers 11.TOW 12.Unit 17.Waste Codes HM and Farddng Group('d any)) No. Type Quantity Wt_Nol. ce I j 2. W 3. f 4. 14.Special Handling Instructions and Additional Information 15. GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are Uy and accurately described above by the proper shipping name,and are classified,packaged, marked and labetedlplacarded,and are in all respects in proper condition for transport according to applicable international and natwnal govemmenlal regWations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAClcnowledgment of Consent I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I em a large quantity generator)or(b)(if I am a small quantity generator)is true. GeneralDes0ferors PrirtedJyped Name Signature Month Day Year r3 —J18..International Shipments . F. ❑lmport W U.S. ❑Export from U.S. Port of entrylexit: z Transporter signature(for exports only): Date leaeing U.S.: 17.Transports'Acknowledgment of Receipt of Materials Transporter 1 PdntedfTyped Name Signature Month Day Year O co co _ Transporter 2 PhnlaOyped Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue El Partial Rejection ❑Full Rejection Manifest Reference Number 18b.ANemate,Facility(or Generator) U.S.EPA ID Number C3 Z� Facility's Phone: 18c.Signature of Alternate Facility(or Generate) Month Day Year C7 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 2. 3. 4, 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintaCyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY