COMPLIANCE INFO_2020 - Laserfiche WebLink

Home Browse Search

Please prini or type. Form Approved.OMB No 2050-0039 UNIFORM HAZARDOUS 1,Generator ID Number ry 2.Page 1 of 3.Emergency Response Phone TTManifest Tracking Number WASTE MANIFEST 2 1G B F - 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) Garerator's 5.Transporter I Company Name U.S.EPA ID Number VAL Lt- 7 Transporter 2 Company Name U.S.FPA D Number 8.1 Facility Name and Site Address U.S.EPA ID Number .if I L Facility's Phone'-'"'t''`1 L3'� ga. 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 Wit fvol. I i I P LU ;-1-1 2. LLI 3. 4 14.Special Handling Instructions and Additional Information It ;i "i6' �;('P til-r4l 6.UIL i 15. GENERA70R'SIOFFEROR'S CERTINCATION: 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 abele#lacarcled,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 minini statement identified in 40 CFR 262 27(a)(it I am a large quantity generator)or(b)(if I am a small quantity generator)is true. Generator's!Offeror's Printedi Name Signature Month Day Year 16.International Shipments Ellmi to U.S, ❑Export from U.S. Port of eni Transporter signature(for exports only): Date leaving U.S., W 17.Transporter Acknowledgment of Receipt of Materials LLJ Transporter I Printed.rTyped Name Signature Month Da.y. Year 0 0- U2 Trans 2 Prrited7yped Name Signature Morith dav year*' tY 18,Discrepancy 18a.Discrepancy indication Space ❑ Quantity El Type ❑Residue El Partial Rejection ❑Full Rejection Manifest Reference Number: >- U.S.EPA 10 Number I.— 18b,Alternate Facility(or Generator) ZI cQi Facility's Phone: Month Day Year LOU 18c Signatura of Alternate Facility(or Generator) 19.Hazardous Waste Report Management Method Codes(I e..codes for hazardous waste treatment,disposal,and recycling systems) LU I 2. 3. California rel C1 I I Notice. State Of photocopy and Ill to 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a generator to D_fSC With 30 %4 ,aVS; Pdntedrfyped Name Signature P.o Box 400 SaCrat-nentCip CA 95812-1 EPA EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. �L:I J CKA I[-KI S NI I T IAL C U'L