Laserfiche WebLink
p.3 <br /> Please print or type.(Form designed for use on elite(t2-pit:h)typewriter.) Farm Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page i of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST c <br /> ...5* 'r�� 'V M <br /> 5.Gene;aces Name and Mailing Address Generators SiteAddress(if different than mailing address) <br /> Gererator's Phone: <br /> 6.Transporter 1 Company Vane U.S.EPA 10 Number <br /> 7,T'ansporter2 Company Name U.S.EPA 10 Nur-ber <br /> 8,Designated Facility Name and Site Address U.S.EPA 10 Number <br /> Facility's Phone: <br /> 9a. 9o.U.S.DOT Descrpbon(including Proper Shipping Name,Hazard Class,IO Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Padding Group If any)) No. Type Quanffity Wt.Nol. <br /> O 1. <br /> z 2. I i <br /> LU <br /> t:3 <br /> i <br /> 3. I <br /> t <br /> E E <br /> a. 4 <br /> p <br /> t <br /> Y t <br /> t p <br /> 14.Special HarAlinc instructions and Additional Information <br /> 15. GENERATOR'SJOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are dassfied,package(k <br /> marked and fabeledlptacarded,and are in ail*expects in proper condition For transport according to applicable international and national governmental regulations.if export shipment ane 1 am the Primary <br /> Exporter,I certify that the contents of this consignment conform to tine terms of the at-achad EPAAcknowledgment of Consent <br /> I certify that ttte waste mirnimization statement identified in 40 CFR 26227(a)it I am a large quantity generator)or(b)(If I am a small quantity generator;is true. <br /> Genermofs0lfero s PrintedrTyped Name. :' _ Signature Month Day Year <br /> J 16:1rtiernationalShipments <br /> 0 import to U.S. ❑Export from U.S. ' Part`of%ntry;ex t <br /> Transportersignature(for exports only): Date leaving U,S.: <br /> 17.Transputer AcknoMedgment of Receipt of Materials <br /> Transporter t Printed/Typed Name Signature Montn Day Year <br /> O <br /> G. <br /> QTransperter2 PrinlWyped Name Signature Mo ntlt Day Year <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space 0 Qu.1ity ❑Type ❑Residue tJ Partial Rejectionj <br /> ❑Frill Rejection <br /> Manifest Reference Number: <br /> 1 Bb.Alternate Facility(or Generator) U-S.EPA ID Numter <br /> a <br /> Facility's Phone: <br /> W18&Sicnature of AIL-matt Facility(or Generator; Morth Day Year <br /> a <br /> Z <br /> 19.Hazardous Nasse Repert Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> ® 1. 2. <br /> 20.Designated Faciity Cwner or Opawcr:Certification of receipt of hazardous materials covered by the manifest except as nded In Item 189 <br /> Printedffyp>edName Signature Month Day Year <br /> =PA Form 8700-22(Rev.305) Previous editions are obsolete. GENERATORS iMMAL C3- PY <br />