COMPLIANCE INFO 2009 - 2010 - Laserfiche WebLink

Home Browse Search

Please print or type. (Form designed for use on elite (12-pilchtter.) • Form Approved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. UNIFORM HAZARDOUS 1. Generator IO Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST SKS 5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) Geneiatoes Phone: 6: Transporter 1 Company Name U.S. EPA ID Number 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address - - - - - - - U.S. EPA ID Number Facilitys Phone: ga. 9b. U.S. DOT Description (inducting Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11.110131 12. Unci 13. Waste Caries No. Type HM and Pecking Gm d n9 up( arry)) Quantity WI./Vol. 1. O 0 W V 3. 4. 14. Special Handling Instructions and Additional Information 15. GENERATGR'SIOFFEROR'S CERTIFICATION: I hereby declare Nat the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labela9placerded, and are in all respects in proper condition for managed according to applicable international and national governmental mgulatiats. If export shipment and I am the Primary Exporter, I cmBfS that the contents of this consignment conform to the terrta of the attached EPAAcknowledgmem of Consent. I ce* that the waste minimization statement identified in 40 CFR 262.27(a) fd I am a large quantity genendw) or (b) (BI am a small quantity generator) la true. Generetors/Offeroes Pdntedrfyped Name Signature Month Day Year �J r— 16. International Shipments ❑Import N U.S. ❑Expert from U.S. Pod ofenhy/exit = Transporter signature (for exports only): Date leaving U.S.: W17. Transporter Acknowledgment of Receipt of Materials Transporter 1 PrimediTyped Name - Sgnatwe Month Day Year O a w Transporter 2 PdntedRyped Name Signature Monty Day Year K r 18. Discrepancy I 18a. Discrepancy Indication Space ❑ Dust ly ❑ Type ❑ ej ❑ Full Rejection El Partial R action Manifest Reference Number. 18b. Alternate Facility (or Generator) U.S. EPA ID Number J V Facifitys Phan: W 18c. Signature ofABemate Facility (or Generator) Month Day Year a z N19. Hazardous Waste Report Management McUrod Codes (i.e., codes for hazardous waste treatment, disposal, and recycling syshams) C 1. 2. 3. 4. 20. Designated Facility Owner or Operator. Ceri ficatwn of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pdntedrfyped Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete.