COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

Please print or type.(Form designed for use on elite(12-pitchwriter.) - Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phon 4.Manifest Tracking Number WASTE MANIFEST �� 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) Generators Phone. 6.Transporter i Company Name U.S.EPA ID Number 7,Transporter 2 Company area _ U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S,EPA ID Number Facility's Phone. 9a. 9b,U.S.DOT Desorption(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12. HM and Packing Group(if any)) Unit No, Type Quantity Wt./Vol.Unit 13.Waste Codes O¢ i W 2. ✓9 3. 4, r 14.Special Handling instructors and Additional Information 15. GENERATOR'S/OFFEROR'SCERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placertled,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 Exporter,I hardly that the contents of this consignment conform to the tens of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quantity generator)or(b)(if I am a small quantity generator)is true. --awl--awl sVitvut s Pulled,I yped Name lgna ure on ay ear J 16.Intemalmnal Shipments ❑Import to U.S. EJExpertfrom U.S. Pod of entry/exit: Transporter signature(for rts Onl -- Dateleavin U.S.'. W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Pnmed7Typed Name ignature Month ay Year w QTrensporter2PrinteNTyped Name ignature a, Month Day Year j18.Discrepancy 18a.Discrepancy Indication Space Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest F Reference Numbe18b.Alternate Facility(or Generator) r: J U.S.EPA ID Number U Q LL Facili 's Phone'. w18c.Signature ofAkemate Facility(or Generator) Q Month Day Year z H19.Hazardous Waste Repos Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 2. 3. 4. 20.Desgnated Facility Owner or Operator:Certification of recept of hazardous materials covered by the manifest except ns noted in Item 18a Printed7Typed Name Signature Month Day In EPA Form 6700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR