COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

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 i of 3 Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST i;:r1T„0+3ft 1NA .5A ri "e'.'�i�I+"2 (�t,�4 9 -11525 FLE 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) x,.'4,'.4 F'' Gsnererors Phone: U.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 CIA, Facilites Phone: 9a. 91%U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.T1111 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt./Vol. I--, , ty atx a 91(1111 2.22 z Z. W C7 3. i 4. i 1 i 14.Special Handling Instructions and Additional Information �y 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 terns of the attached EPA Acknowledgment of Consent. I cattily that the waste minimization statement identified in 40 CFR 261(if I am a large quanbly generator)or(b)if I am a small quantity generator)is ave. enerator rots PdntedRyped Name igna ure on ay ear e stn'ry J16.International Shipments r ❑Import to U.S. ❑Export from U.S. Pod of entry/exit: z Trans iter signature for exports only): Date leaving U.S.: W 17.TronsporterAcknowledgment of Receipt of Materials K Trenspener 1 Printed/Typed Name Sgirair y t. Month Day Year 13-N Q Transporter PnntedlTypetl Name Signature t Month K H } 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U a r+- Facili s Phone: - w 18c.Signature of Alternate Facility(or Generator) Month Day Year zz 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1. 2. 3. 4. 20.Desgnated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a - PdntedlTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY