COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

Please print or type. Form deli r1eQ for use on elite 12 -pitch) plrwriter) Form Approved. OMB No, 2050-0039 EPA Poral d/UU-ZZ (Rev. 3-U5) Physicals editions are obsolete. AWSIGNATED FACILITYTO DESTINATION STATE (IF REQUIRED) UNIFORM HAZARDOUS 1, Generalcr 10 Number 2. page 1 of 3 Emergioncy Pesprinsa Phone .Manifest rackin Number WASTE MANIFEST 0000 1591 DAT 5. Elemental Name and Mal Address GenmatoeS SRI) M crass (if ddkranl than maAing address) General phone: - .. _... 6 Traruporl i Company Name U.. S. EPA ID Number 7. Transport 2 Company Name U.S. EPA ID Number F Lye- t Gly 8 Ussignated Fanay Name and Silt, Address U.S. EPA ID Number Farlfity's Phone, ga, 9b, U.S.D97. Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Tatal 12. Unit HM and Parking Group!if any)) Ouai M/LN01. 13. Waste Codes No. Type 003 Z 2 w 00i q30low -- il&e" gr 4. 14. peda andfrig Instructions artl Additional Infurnafion 45. GENERATOR'S/OFFEROR'S CERTIFICATION; I hereby declare that the =fonts of this consignment an, fully and accurately described above by the proper shipping name, and are classified, packaged, marked and Iebolodlplaparded, 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 cemfy that the contents of this consignment conform to the tennis of the attached EPA Acknowledgment of Consent. I codify that the waste minimization statement identified In 40 CFR 262.27(a) (if I am a large quantity generale) or (b) (if I am a small quantity generator) Is We. Generatefsl0fflroes PrintedrTyped Name Sgralue month Yew 1 . Interna onal 4 pments El Import to U. S. ❑Expmthor z U,S_ earentry/exit: Transporter signature (for exports only): Data leaving U.S: 17. TransporterAcknowiedgmenl of Recelptof Materials OThai 1 Pnmmviyped Name S{gnatura Montle Day Year i i7 Z tans e 2 Pon yped foam sig ra Mom DayYear i6. Dlacrelow15 1 Be. Discrepancy Indication Space ❑ Quantity ❑Type. U Residue ❑Partial Rejection ❑Fut, Rejection Manifest Reference Number: 18b. Altemeio Facility (or Generator) U.S. EPA ID Number J V Facility's Phone: W lac. Signature of Alternate Facility(orGenerator) Month Day Year Q 2 N19. Hazardous Waste Report Management Method Codes (ie,, codes for han*us v;asn,treatment, disposal, and recycling systems) p 1. 2. 3. 4 20, Designated Facstity Owner or Operator'. Certification of receipt of hazardous materials covered by the harshest except as noted In Item 18a Ph1[ ed Name, C -vi MOMh Day Year J n EPA Poral d/UU-ZZ (Rev. 3-U5) Physicals editions are obsolete. AWSIGNATED FACILITYTO DESTINATION STATE (IF REQUIRED)