Laserfiche WebLink
is *f-anilil T, Maii a ea¢u to. t 9 PA Box 400 Sacramento, Ga SM 2-t <br />Please mint.ortvoe. (Form designed for use on elite (12 -DRO) tvoewriter.) <br />wlthinsoduyo.''° <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS 1 Generator 10 Number �+ <br />WASTE MANIFEST i! .j�'�' <br />2. Page 1 of <br />Y <br />3. Emergency Response Phone <br />�i y�' r7•�.^4i�Q <br />4. Manifest Tracking Number <br />00864281,0 JJ <br />5. Generators Name and MaitingAddress ,. e�-� y r , ,t� yJfw � r r „r. Generators Site Address if different than mailing address) <br />, <br />Gen tors Phone: <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />rc,, •^r T 5;;.:emWriai>a; w GP118924t3282 <br />7. Transporter 2 Company Name U.S. EPAID Number <br />8. Designated Facility Name and Site Address U.S. FPA ID Number <br />�la!gfCci, e}18 sr; <br />FtU@sn.� �eilt$il i� tri <br />FaciliNs Phone; <br />9a. <br />9b. U.S. DOT Descriplim (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />Na. <br />Type <br />HM <br />Gro <br />and Packing up (if any)) <br />Quantity <br />WtNol. <br />LJ <br />3. <br />4. <br />1 pedal Handling Instructions ad Additional Information <br />1 rl�y %71 JW,P1 - s s- <br />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, <br />marked and labeled/placamed, and are in all respects in proper condition for transport according to applicable international and national govemmentai regulations. If export shipment and I am the Primary <br />Exporter, I oe* that the contends of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certky, that the waste minimization statement Identified in 40 CFR 262.27(a) (if I am a large quantity gen wovr jir (b) (if I am a small quantity generator) is true, <br />Generators/Ogeroes Prntedayped Name Signaaire Month Day Yaw • <br />/ <br />f <br />16. International Shipments <br />❑ Impon to U.S. ❑ Export irem U.S. Por of entry/writ <br />Transporter signature (for expors only): Date leaving U.S.: <br />17. Transporter Acknowledgment of Receipt of Materials <br />KTmnspo <br />Name Si - '? Month Day Year <br />t 1 PIntedlTyped /.a <br />;Q <br />Transporter 2 Fnnled/Typed Name Signature Month Day Year <br />C <br />H <br />18. Discrepancy - <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />Facility's Phone: <br />18c. Signature of Alternate Facility (o Generator) <br />Month Day Year <br />a <br />Z <br />S2 <br />19. Hazardous Waste Report Management Method Codes (i.e.. codes for hazardous waste treatment, disposal, and recyding systems) <br />C <br />1. <br />2. 3. <br />4. <br />20. Designated Facility Dwner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />1 <br />PdntedfTyped Name cignature Month Day ear <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />