COMPLIANCE INFO 2010 - 2014 - Laserfiche WebLink

Home Browse Search

"'i ...i Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST 01" 917986 JJ K 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) Generators Phone: 6.Transporter 1 Company Name 9 A===... %0 L.I V EPA ID Number 7.Transporter 2 Company Name NOV 13 O p 2014 U.S.EPA ID Number 8.Designated Facility Name and Site Address L U.S.EPA ID Number ENVIRONMENTAL HEALTH DEPARTMENT Facility's Phone: ga 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 Vi13.Waste Codes olO z 2. w r7 3. 4. 14.Special Handling Instructions and Additional Information 15. GENERATOR'S/OFFEROR'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 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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement 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. GeneratoestOReror's Printed/ryped Name Signature Month Day Year 6.International Shipments r ❑Import to U.S. ❑Export from U.S. Port of enirylezd: z Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed(ryped Name Signature Month Day Year O zQTransporter 2 Prince yped Name Signature Month Day Year r 18.Discrepancy Its.Discrepancy Indication Space ❑ Quantity El Type El Residue Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: w like.Signature of Alternate Facility(or Generator) Month Day Year 6 Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1. 2. 3, 4. 20.Designated Facility Owner or Operator:Cadification of receipt of hazardous materials covered by the manifest except as noted In Item 18a 11I PrintedRyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete._ :Mi-.BATOR'S INITIAL COPY