COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

111111111111111111111111111111 IT II //�� 005 '1 0637 9S KS Please print or type.(Form designed for use on elite(12-pitch)typewriter.) 5�V Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2,Page i of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST 2- 1005106q79 SKS 5.Generator's Name and 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 2 Company Name U.S.EPA ID Number L Le A,,41 /-I 2Z27-5C-1 8.Designated Facility Name and Site Address U.S.EPA ID NUmber Facility's Phone: ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. t. C CI f CC) 0 o - z 2. w 3. I 4. i I 14.Special Handling Instructions and Additional Information 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classed,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 26227(a)(if I am a large quantity generator)or(b)(if I am a small quantity genera true. Generators/Of ereror's P�rmtted/Typed Naamme,,� �\ Signature Month Day Year c-, C � 16.International Shipments Z ❑Import to U.S. El Export from U.S. Port of entrylexit: Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year U) i9'� ar �.�- i2 /77 IS CL t N Q Transporter 2 Printed/Typed Name Signature Month Day Year 1r 18.Discrepancy 18a.Discrepancy Induction Space Q aril,_, ❑Type ❑Residue ❑Partial Reject on ❑Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Facility's Phone. w 18c.Signature of Altemate Facility(or Generator) (.Month Day Year Q z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) p 1. N 1, (q 1 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Q t Signature P.1 nth ay Year 1 - t EPA Form 8700-22,(Rev.3-05) Previous editions are obsolete. DESIGNATED FA TO DESTINATION STATE(IF REQUIRED)