Laserfiche WebLink
Please print lir type.(Porto designed for use on elite(12•pitch)typewriter.) "+ Farm Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.GeneratorlD Number 2.Pagelof 3.Emergency Response Phone 4.Manifest Tracking Number �( <br /> WASTE MANIFEST JJ K <br /> 5.Generators Name and Mailing Address Generators Site Address(A different than mailing address) <br /> Generator's Phone' <br /> 6.Transporter 1 Company Name U.S.EPA IO Number e <br /> T.Transporter 2 Company Name U S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA 10 Number <br /> Facialis Phone: <br /> 9, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number. 10.CaMziners11.Total 12.Unit <br /> HM and Packing Group IN any)) No. Type Quantity Wtivol. 13.Waste Codes <br /> L <br /> C <br /> O4 <br /> W 2 <br /> 1u <br /> 49 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are Nay and accurately described above by the proper shipping name,and are classified,packaged, <br /> 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 <br /> Exporter,I mrdly that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent <br /> I rarely that the waste minimization statement identified in 40 CFR 262.27(a)in I am a large quantity generator)on(b)(81 am a small quantity generator)is true. <br /> GeneretorslOgeroes Pdnteddryped Name Signature Month Day Year <br /> J 16.International Shipments <br /> i- ❑Import b U.S. ❑Export from U.S. Pon of entry/exit <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> C Transporter l Ptintednitmed Name Signature Month Day Year <br /> O <br /> 0 <br /> QTransporter 2 Pdntedfryped Name Signature Month Day Year <br /> C <br /> r <br /> � �18.Discrepancy <br /> 16a.Discrepancy Indication Spam ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> ) Manifest Reference Number. <br /> F tab.Allernam Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> W Facilitys Phone' <br /> use 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z <br /> v—i 19.Hazardous Waste Report Management Method Codes(Le..odes for hazardous waste treatment.disposal,and recycling systems) <br /> 3. 4. <br /> 20.Designated Facility Owner or Operator.CeNfimbon of receipt of hazardous materials covered by the manifest except as road in Item 18a <br /> Prmtedflyped Name Signature Month Day Year <br /> EPA Form 8700-22 fRev.3-05) Previous editions are obsolate. --- -- ----- ---- -- - -- <br />