COMPLIANCE INFO_PRE 2019 - 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 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST _ 006ru,'26734 JJ K 5.Generator's Name and Mailing Address Aft r»� TMi , }),,l .;,rtit,t Generator's Site Address(d different than mailing address) R^?sl E1A� M3f,:? EN T Lre`r Ot1tJt r P i-0 00'X"24056,MS 704 PARDEE DAM RC+ )AKI.Ai '7A 04357't..9656 11ALLE`i' aPP*Jf,3S i-'A Mt"*02 Generators Phone: f? T 6.Transporter 1 Company Name U.S.EPA ID Number IRS FP {?Pbt bEf.i1C 4 SEP ij1�f71: :;a^ 3+ R al 0 0 0 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number i Facility's Phone: w' 4 K-54.4' 9a. 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. 9. ` art'•7,. ',,.fi'(lojs wal'stw,301W.I� w t, o t =JJi f'r1if1�IR13 Jb"' �¢� L Z 2 W 3. 4. 14.Special Handling Instructions and Additional . 114 4 4A t.--PRr1qTCT.r. trr.r 3 Wrfi .1 t PICA-5.1576 E►ph'1,"rbr asVV76E PARDEE CTIR r,TP4" J*J"1t1,rTRM4rNT L "t .rrf"E,$t TW- 1.O0g 1PJ~+Y Pr:'Tlfr, A1.411rPA, (!A 94SO1. 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 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/Offerors Printed/Typed Name Signature Month Day Year J 16.Internationals Feats - ElImport to U.S. ElExport from U.S. Port of entry/exit. Z Transporter signature(for exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed(Typed Name Signature Month Day Year J4 Ma, Z Transporter 2 Printed/Typed Name Signature Month Day Year Q 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 LL- Facility's Phone: LO 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 0 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 Pnnted/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY