COMPLIANCE INFO_2020 - Laserfiche WebLink

Home Browse Search

Please print or type.(Form designed for use on elite(12-1 typewriter.) Form Approved.Ol No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST G B F 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generator's Phone: o.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8-Deslgnaled Facility Name and Site Address U,S,EPA ID Number Facility's Phone: 93. 9b,U-5 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 WI.NoI. O a rr w z 2, LLL C7 3. 4 14.Special Handling Instructions and Additional Information 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, marked and labeledlplacarded,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 FPAAcknowledgment of Consent, I certify that the waste minimization statement identified in 40 CFR 26227(a)(if I am a large quendly generator)or(b)(if I am a small quantity generator)is true, Generatohslefferor's PrintedlTyped Name Signature Month Day Year J 16.lnlernationai Shipments ❑Import to U - ❑Export from U S. Pod of entrylexit: Transporter signature(for exports only): Date leaving U.S.: Ll 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year O a rn Transporter 2 PrintedlTyped Name Signature Month Day Year a 18.Discrepancy 18a,Discrepancy Indication Space ❑ quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: F 18h.Alternate Facility(or Generator) U.S.EPA iD Number J_ U LL Facility's Phone: 18c.Signature of Alternate Facility(or Generator) Month Day Year a z y19.Hazardous Waste Report Management Mothad Codes(Le,,codes for hazardous waste treatment.disposal,and recycling systems) 0 1. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedfTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL C011