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 UNIFORM HAZARDOUS t�✓Generator ID Number 2.Page 1 of 3.Emergency Response P 4.Manfkd}Tr8640246 acid�nnn+q Number �+ WASTE MANIFEST C. Lo 00 �S'"�1 I a d 9- t" ®1 O V 4® 6 JJK 5.Ganaralo s Name and Mail'29 l Vs L �/�g CGo ralol s Site Add rent than melting address) 1C! G-32700 .4; - 9L DIDAACO 6S7- /i!✓e, f .47M.-SWV&,VS4A7ZR Generator's Phone: EEE I 6.Transporter i Company Name U.S.EPA ID Number L- sP ?7d I-LC rA I 1-V 7,Transporter 2 Company Name U.S.EPA ID Number 6.Desi na Faa ityyNa rq SjteAde ss ro /�� U.S,EPA ID Number C> Hj k t [ Facility's Phone: 60 2-+"' �+ 9a, 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 WtNol. cc t it ®Yt j�� s �®t/ PAJ V=4 Tr yev), 1, 3. 4. 14./operaai Hand3ing lAo/hI e-ucko and Addt�onal�n �1 4J ru m ' !i 12.8 ® r - �6&v 15. GENERATOR'SIOFFEROR' ATiON:I heieby declare that the conteids of this conslgiirtnent are fully and aocutateiy deacilsed above by the proper shipping name,and are classified,packaged, marked and labaled/placarded,and are in all respects in proper condition for transport according to applicable intonational and national governmental regulations,if export shipment and i am the Primary Exporter,t certify that the contents of this consignment conform to the terns of ft attached EPAAdrrwMedgment of Consent I cerldiy that the waste minimization statement identified In-40 CFR 26227(a)(91 am a large quantity generator)or(b)(di am a small quantity generator)is true. Generator'sA7#feror's Printed/Typed Name Signature &7 Month Day Year 16,International Shipments a-- ❑Import th U.S. ❑Expert from U.S. Pot of enbylexil: Transporter signature(for exports only). Date leaving U.S.: 11,Transporter AcRn wh*ment of Receipt of Materials Uj w Transporter 1 PnntedfTyped N S1g tatura Month Day Year a- na MG/G U) Transporter iin',edtfyped Name Signature Month Day Year cc t- 16.Discrepancy 19a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Fwi Rq t;en Manitrrst Reference Number. 16b.Alterrats Fadliy(or Generator) U.S.EPA ID Number r`a L Facility's Phone: w f Co.Sgnature of Alternate focality(or Generator) h#ontdr Day Year 19.Hazardous Waste Report Management Method Codes(.e.;codes for hazardous waste trealment disposal,and recydirg systema) LLJ 1. 2 13, 4. 24.Das graded Faclihf Owner ,or Opamfor.Certification of ra*t of hazardous materials covered by the manifest except as nded in item lea Pdntedtfyped Name gnature Manch Day Year EPA Form 8700.22(Rev,3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)