COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

Please print or type.(Form designed for use on elite(12-pitch)ty'ter.) Form Approved.OMB No.2050-0039 UNIFOZM HAZARDOUS 1.Generator ID Number 2.Page 7 of 3 Emergency Response Phone 4 Manifest rocking Number WASTE MANIFEST �� t...,.� ,( '' .�.. + ' '� L° 7 r' 4' /130 JJ K ;.Generator's Name antl Mailing Address Generator's site Address if different than mailing address) Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter Company Name r _ LLS.EPAID Number 8,Designated Facility Name and Site Address U.S.EPA ID Number FaclI s Phone: J' r• . i'1� ' i.ty ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers HM and Packing Group(if any)) 11.Total 12.Unit 13.Waste Codes No. Type Quantity WLN01. Of is Z 2. a. 3. 4..' Special Handling Instructions and Additional Information S`1 15'. GENEP.ATOR'SIOFFEROR'S CERTIFICATION: (hereby declare 0�at the contentsof this consignmentsare fully and accurately described above by the proper shipping name,and are classified,packaged, marked and Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable intemadonaland national governmental regulations.If export shipment and I am the Primary Exporter,I cedify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment 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. Genermars/Offerors Pdnted/Typed Name Signature Month Day Year —al 16.International Shipments - F ❑Import to U.S. El Export from lLS 1 Port of enhylexit: Transporter signature(for exports only): Date leaving U.S.: of 17.TmnspotlerAcknowledgment of Receipt of Materials Transporter l Pdnted(Typed Name Signature Month Day Year, O r : CTransporter Printadrryped Name Signature Monthr Day Year K F 18.Discrepancy 18a.Discrepancy Indication Space ❑ I ❑Full Rejection Quantity Type Residue Partial Rejection Marl 1 n u r 18b.Alternate Facility(or Generator) IUS. - er J fp1 LL Facilkys Phone: MAY U 21 Ol/ C3 fee.Signature ofAltemate Facility(or Generator) FMonth Day Year PF12AAI!4c-sl ,. I� Hazardous Waste Report Management Method Codes(i.e.,codes far hazardous waste treatment disposal,and recycling systems) ` ICG 2' 3. 4, 20.Designated Facility Owner or Operator.Cedi6cetion of receipt of hazardous matedals covered by the manffest except as noted in Item 18a Pdntedrryped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY