COMPLIANCE INFO_2020 - Laserfiche WebLink

Home Browse Search

Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No 2050-0039 '°NIll HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number G B F r WASTE MANIFEST 5,Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generator's Phone: S.Transporter 1 Company Name U.S.EPA Ip Number 7 Transporter 2 Company Name U.S.EPA ID Number S.Designated Facility Name and Site Address U.S.EPA ID Number 'r'1Si f:E:iYILdFt'b� [rlVlfdit. .. : :. 2Q3l5 iNEWLAN 3S Dpi.Eiiiii FFFRlhill Y.f4V ,tA8408 Facility's Phone: 9, 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 WLNoI. 1 KV)prt••tdL:($fi HAZARDOUS ItU.AS TE, 80LI1 a 01R.T.tliL GF21E:�SE rY LU M 2 LU C7 3. a 14,Special Handling Instructions and Additional Information -w,�: �,>*ys, Gil, 15. GENERATOR'SfOFFEROR'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 labeledlpiacarded,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. GeneratoeslOffeor's PrintedlTyped Name V-- Signature Month Day Year 16.Intemalional'Shipments F ❑Import to U.S. ❑Export from US. Porf of enlrylexit: _ Transporter signature([or experts only): Date leaving U,S.; W 17-TransporterAcknowledgment of Receipt of Materials W Transport9r 1 PrintedlTyped Name Signature Month Day Year O Z Transporter 2 PrintedlTyped Name Signature Month Day Year a tY 18.Discrepancy 1�a Discrepancy Indication Space ❑ quantity ❑Type5 I P Ll Residue 2�P eec�f n mi � F��Reeclion has the appropriate per Manifest Reference Nu be accept the Wl 18b-Alternate Facility(or Generator) S.EPA rjS Shipping. ping• this genesd��' p U rQi Facility's Phone; th Day Year 1W 1 Be Signature of Alternate Facility(or Generator) Mon r— a Z 55 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 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 PrintedlTyped Name Signature Month Day Year EPA Form 8700-22(Rev 3-05) Previous editions are obsolete. ! DESIGNATED FACILITY TO GENERATOR