CO0038836 - Laserfiche WebLink

Home Browse Search

At P type. 9 ( 2-pitch)typewriter.) FApproved.\ 1rNfB�� Please print or t e. Form designed for use on elite 12- itch t ewriter. orm 0 No.200-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Trackin Number WASTE MANIFEST C;, t 11 t 111,10'•i- ,;r;'.z�� -,•. . O 0 9 77 b 8 6 6 JJ K 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) UrhluitTm.Lkuy Lao Jit tai-i r.::u t I SC, µ0. W)v AW Jrl1� tomo P6 1/11f SmOh oxf I,*gF*vay 4 ;ra.l:P tot W42 14rr onn VA 91715 Generator's Phone: o _, 6.Transporter 1 Company Name U.S.EPA ID Number ,Ctt'sP'a 7.Transporter 2 Company Name U.S.EPA ID Number' I,.1X' r-nvir r;nrrtr,rrtal 5e.vice sir t P43nw la-L>•' 8.Designated Facility Name and Site Address U.S.EPA ID Number 2+to Cal A W y Err.it Unne4 a ai NIa tia pe"wa of East(VeWlarvds tlrvve -�. NV 8&401 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)) 13.Waste Codes No. Type Quantity Wt.Nol. 1. 0 X L)N1U11,Waste Ekkane,2.1, RO(DOUI) Q w M 2. w c7 3. 4. 14.Special Handling Instructions and Additional Information tfwos to order, 11r- C.H Lt B x,r,in Lialo-Wear apprc4xicrle pet s"I pt of tGtnt -e ell4riMC-N'vvtke1n, h 1(1 xi�i Job#5769 Cl ZJ 14-11-OU4 ` 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 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. Generator's/Offeror's PrintedlTyped Name Signature I Month Day Year 16,International Shipments ►- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: z 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 N i j ZZ Transporter 2 Printed/Typed Name Signature Month Day Year r 18.Discrepancy 18a.Discrepancy Indication Space ❑ Type Quantity T e Residue ❑ Partial Rejection Full Rejection Manifest Reference Number: 18b,Alternate Facility(or Generator) U.S.EPA ID Number J U ua Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year a z 0 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 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 Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY