COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

IIIIIIII INNII IIIIIIIII II IIII IIIS Please print or type.(Form designed for use on elite(12 pitch)typewriter) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number _ - 2.Pag;1 of 3,EmefgIMy Recppnse(hope;_. 4.Manifest TTrrac[kln Number [] SKS WASTE MANIFEST O O S J 2 3 O 3 J V„S 5.Generators Name and Mailing Address Generators Site Address(if ddfemnl than mailing address) Generators Phone: U.S.EPA ID Number s.Tfarlspoger-1,CompaM'-�l!le , 7.Transporter 2 Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address _ - ,, U.S.EPA ID Number Facility's Phone: ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit "HM and Packing Group if any)) No. Type Quantity Wt.No1. 13.Waste Codes 60 z Z. Liu 3. 4. • 14.Special Handling Instructions and Additional Information 15. GENERATOR'SIOFFEROR'S CERTIFICATION: Ihereby declare that the contents of this consgnment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and Iabeled/placarded,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 Dose . I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or ('dl a small quantity generator)is true. Gene rots Printed/fyped flame Signature Month Day Year 16.International Shipments Export from U.S. Portof .try/exit: F ❑Import to U.S. = Transporter signature(for exports only): Date ing U.S W 17.TmnsporlerAcknowfedgment of Receipt of Materials K Transpoltr 1 Pnntedfryped Name r Signature Month Day Year a � C7( O117 QTransporter 2 Printed/fyped Name Signature Month Day Year C r 18.Discrepancy lea.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Parlial Rejection ❑Full Rejecdon Manifest Reference Number: 181h.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: w 18c.Signature of Altemate Facility(or Generator) Month Day Year Q (D 19.Hmardo s Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 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 lill Printedrryped� Sig naWr Month Day Year ♦ WA c EPA Fomk$700.22(RINIY 3A5) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REOUIR D)