Laserfiche WebLink
oi.. . �- ,C...., 4 —A r.. alit. r17_hifrhl h --it— 1 <br />Form Approved, OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. <br />TRANSPORTER'S COPY <br />UNIFORM HAZARDOUS <br />1 Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number p <br />0 0 9 i" S, 3 G D F <br />WASTE MANIFEST <br />, -. <br />� <br />5. Generator's Name and Mailing Address <br />Generator's Site Address (if different than mailing address) <br />f,g+,>•jai": ' q,i' . <br />Generator's Phone: <br />6. Transporter 1 Company Name <br />U.S, EPA ID Number <br />0. <br />I I, 4,1 `I, <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />B. Designated Facility Name and Site Address U. . EPA ID Number <br />Facility's Phone: <br />9a <br />9b. U.S. DOT Description (including Proper Shipping Name, H <br />zard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13, Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />ir <br />1. ,.kiZb Ffa rtrg` tr 1 t It, . rr! <br />41F'' <br />, _, <br />^}F- <br />O <br />Z <br />2. <br />W--- <br />0 <br />-- <br />—` <br />3. <br />7 <br />4. <br />14. Special Handling Instructions and Additional Information <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare <br />that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br />marked and labeled/placarded, and are in all respects in proper donclition <br />for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform <br />W the terms of the attached EPAAcknpwledgment of Consl <br />I certify that the waste minimization statement identified in 40 CFR <br />262.27(a) (if I am a large quantity generator) or (b) (if I a a small quantity generator) is true. <br />.Generator'slOfferoes PrintedlTyped Name <br />Signature Month Day Year <br />F <br />16. Interritighal Shipments <br />❑ Import to U.S. <br />❑ Export from U.S.. Port of entrylexit: <br />z <br />Transporter signature (for exports only): <br />If Date leaving U.S.: <br />% <br />17. Transporter Acknowledgment of Receipt of Materials <br />tE <br />Transporter 1 Printed(fyped Name <br />Signature Month Day Year <br />Z <br />Transporter 2 Printed/Typed Name <br />Signature Month Day Year <br />F- <br />18. Discrepancy <br />18a. Discreparicy Indication Space ❑ Quantity <br />❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) <br />U.S. EPA ID Number <br />J <br />V <br />.4 <br />Facility's Phone: <br />W <br />18c. Signature ofAltemate Facility (or Generator) <br />Month Day Year <br />Q <br />Z <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e., code <br />for hazardous waste treatment, disposal, and recycling systems) <br />0 <br />1. <br />2. <br />3• <br />4. <br />Ir <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous <br />materials covered by the manifest except as noted in Item 18a <br />Printe7yped Name <br />Signature Month Day Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. <br />TRANSPORTER'S COPY <br />