COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

IIIII0III6IIIIIlIIIIIIIIIIIIIIIIIIIA Please pant or type.(Fo designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 1 Generator ID Number __ 2.Page 1 of 3.F�mergeoc�- Response Phone_ 4.Manifest T"'07136 ackinpy Number UNIFORM HAZAR US -.: . - - - 10046 J 7 1 3 6 C KS WASTE MANIFE T �f�IItate 1br�r�rp�yr� v 5.Generators Namea Mailing Address _ GeneREU "EI V En�V ), Generators Phone .S.EPAID Number _ i 6.TransP47l€rl Comp yN1me ;r -n ,'tta–• v 4: i 7.Transporter 2 Comp ny Name umber HFA!Tmncpaa AcIIurr 8.Designated Facility ame and Site Address _ i U.S.EPA ID Number r �i IFtJ _ _ Facility's Phone: 9a 9b.U.S.DOT kci(including Proper Shipping Name,Hattard Class,ID Number, 10.Containers11.Total 12.Unit - HM and Packing cup(d any)) No. Type quantity wt/vol. 13.Waste Codes K p c , W i i iL �i 14.Special Handling) stmctions and Additional intonnation ,i 1 __,c;.s 15' GENERATOR' FFEROR'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,packaged, marked and late idlipticarded,and are in all respects in proper condition for transport according to applicable international and national govemmental regulations.I export shipment and I am the Primary Exporter,I ca at the contents of this consignment conform to the terms of the arlached EPAAclmoWedgment of Consent. ti`lp I certify that the este minim¢abon statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(dl am a small quantity generator)is true. 'p I GnsmtorslOfierDrs rinled/Typed NameSig aWre Month Day Year �rz k� ( S. i6. ntemational Ship encs ❑Importb U.S. El Fxportfrom U.S. Pott lof e ' z Date leavingaving U.S.. — Transporter signature or exports only): !w 17.TrensporterAckn ledgment of Receipt of Materials Trani e 1 Printed yped a Signature Month Day Year a �U F V In Transporter 2 Printed yped Name Signature Month Day ear 6 CC > 18.Discrepancy ISa.Discrepancy lndi such Space ❑ quantity ❑Type ❑Residue partial Rejection Full Rejection Manilosl Reference Number. 18b.Altemate Facility or Generator) U.S.EPA ID Number J U LL Facility's Phone: j w 18c.Signature of Ate ate Facility(or Generator) Month Day Year iQ "t 2 . y 19.H3a rd iva Waste Report Management Method Codes(.e.,codes for herardous waste treatment,disposal,and recycling systems) 4. II I I20.Designated Facild Owner or Operator.Certifiration of receipt of hazaMous materials wavered by the manifest except as noted in Item 18a Printedlryped Name Signature Month Day Year i --A Form 8700-22(Re.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)