COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

Y n JV aOV print or type.(Form designed for use on el (12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator IDNtuber 2.JPage 1 of 3.Flrtergenwy Response Phone 4.Manifest Tracking Number WASTE MANIFEST 014789140 JJ K b-Generators Name and Mailing Address - F„ Generators Site Address(if different than mailing address) . J' Generators Phone 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Fadlity,Name and Site Address ,,r I , U.S.EPA ID Number Facillty's Phone: 9a 9b.U.S.DOT Description(mduding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Parking Group(if any)) No. Type Quantity Wtivol. 13.Waste Codes z 2. i! t 3. { 4. i 1 1 14.Special Handling Instructions and Additional Inforr"tion - - - 15. GENERATOR'stoFFEROR'S CERTIFICATION:I hereby dedare that the contents of this cor*nmerd are fully and accurately described above by the proper shipping name,and are classed,packaged, marked and labeled(placarded,and are in all r m 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 conslg erlf conform to the terms of the age0ed EPA Acknowledgment of Consent. I certify that the waste rruntim'rzation statement id tfied in 40 CFR 26227(a)(if I am a large quantity generator)or(b)(ff I am a small quantity generator)is true. GeneratoeslOffemes Printerlayped Name Signature Nonth Day Year -1 16.International Shipments r El Import to U.S. ❑Export tram U.S. Port ofe'�try/exit: Transporter signature(for exports only: Date leaving U.S.: W 17.TiruLvorterActcrwwiedgmerd of Receipt of Materials Transporter t Prfnted/Typed Name Signature Month Day Year a t Y U) Transporter 2 Printed/Typed Name Signature Month Day` Year rY F 18.Discrepancy 18a,Discrepancy Indication SpaceQuan� T Residue❑Type ❑Partial Rejection ❑full Rejection ❑ Manifest Reference Number I— 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Facility's Phone: LU 18c.Signature of Alternate Facility(or Generator) Month Day Year Q 2 E,7 19.Hazardous Waste Report Management Method Cod (i.e.,codes for hazardous waste treatment disposal,and recydmg systems) G 1. 2. 3. 4. 20.Designated Facility Owner or Operator Certification f receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed(TypedName Signature ti;,, Month Day Year EPA Form 8700-22(Rev.3-05) Prevjpus editions are gbsolete. GENERATOR'S INITIAL COPY