COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

OMB No. 2050-0639 1.7GBF 13. Waste Codes 4. f 14.3 cal i g o g n atiog _ Y f l 15. GENERATOR'S10FFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, package, ` marked'end labeledlplacarded, and are in all respects in proper condition for transport according to applicable intematianal and national governmental regulations. If export shipment and tam the Pdmary °. Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgmerrt of Consent. I certify that the waste mWmizatiof.gta[ement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. Generator'sfOfferoes Pdntedlryped Name Signature Month Day Year J 16, In%mational Shipments t - Z ❑Import to U.S. El Export from U.Sr. t Port•ef en;' ]exit: Transporter signature (for exports only): Date leaving U.S.: LU 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signaturey M�h Day Year fA�' it w � — _ . — Month Day Year tr .� H 18. Discrepancy 1Ba. Discrepancy Indication Space ❑ Quantity ❑T e Yp ❑Residue ❑ Partial Rejection ❑ Fuil Rejection 18b. Alternate Facility (or Generator} Manifest Reference Number: U.S. EPA ID Number J_ - Ci rat Facility's Phone: I A 6,19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 1 2• 3. 20. Designated Facility Owner or Operator. Certificef on of recefpt of hazardous materials covered by the m danifest except as noted in Item 18a PdntedlTyped Name Signature EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) Form UNIFORM HAZARDOUS 1. Generator ID Number 2, Page 1 of3. E�rmmergency Response Phone 4. Manifest Tracking Nu WASTE MANIFEST 1, f `i Z"'F' iP } i.� 5. Generator's Name and Mallin .A r ss "— 4 1.,Gerierlilbr's Site Addr ss f different than mailing address) 7. Transporter 2 Company Name U.S. EPA ID Number 8`De4g."JK%Nps and Site Address U.S. EPA ID bei 1191' Itw,t�l' V'� d y�i C*�y{} Facrlity'sPhone: 9a, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit HM and Packing Group (if any)) No,Type quantity WI.Nol. � 1• f �,15,�it°, F3dt�'�lfi� �+'r9»E...l�f� `t.�..'tr sr�3�i'E:R" � � iT ;, „. � 0 . z 2 ' LU CD S OMB No. 2050-0639 1.7GBF 13. Waste Codes 4. f 14.3 cal i g o g n atiog _ Y f l 15. GENERATOR'S10FFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, package, ` marked'end labeledlplacarded, and are in all respects in proper condition for transport according to applicable intematianal and national governmental regulations. If export shipment and tam the Pdmary °. Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgmerrt of Consent. I certify that the waste mWmizatiof.gta[ement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. Generator'sfOfferoes Pdntedlryped Name Signature Month Day Year J 16, In%mational Shipments t - Z ❑Import to U.S. El Export from U.Sr. t Port•ef en;' ]exit: Transporter signature (for exports only): Date leaving U.S.: LU 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signaturey M�h Day Year fA�' it w � — _ . — Month Day Year tr .� H 18. Discrepancy 1Ba. Discrepancy Indication Space ❑ Quantity ❑T e Yp ❑Residue ❑ Partial Rejection ❑ Fuil Rejection 18b. Alternate Facility (or Generator} Manifest Reference Number: U.S. EPA ID Number J_ - Ci rat Facility's Phone: I A 6,19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 1 2• 3. 20. Designated Facility Owner or Operator. Certificef on of recefpt of hazardous materials covered by the m danifest except as noted in Item 18a PdntedlTyped Name Signature EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY