Laserfiche WebLink
C <br />Please Dn t or tvoe (Form des+oned for use on elite (I 2 -Ditch) tvoewriter i <br />0 �\-o 6 <br />Form 2650-0D39 <br />EPA Form 8700-22 (Rev 3-05) Previous eddions are obsolete DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS <br />1 Generator 10 Number <br />2 Page 1 of <br />3 Emergency Response Phone <br />4 Man Trardung Number <br />WASTE MANIFEST <br />Tt1 <br />1 <br />0 <br />F L r- <br />Generator's Name and MaftV Address Generator's Site Address (d dfferent loan maimng ) <br />AFFIX TO RIGHT SIDE <br />S"rn lie OF <br />ALL HAZARDOUS <br />SWdft% CA 95M <br />MATERIALS BILLS AT LINE <br />Generators Phone <br />SOTAB WILL STICK OUT <br />ransporter 1 ompany Name <br />US EPA ID Number <br />wtixrne ra c uwast o aoaafl. wes <br />c <br />7 Transporter 2 Company Name <br />US EPA ID Number <br />8 Designated Facility Name and Site Address <br />US EPA ID Humber <br />1 <br />1 Y <br />But^ AR S <br />Facility's phone <br />ga <br />9b U S OOT Description (mdud#V Proper Shipping Nam Hazard Clams, ID Number, <br />10 Conlainers <br />11 TOW <br />12 Unit <br />Waste Codes <br />No <br />Type <br />HM <br />and PacHrxJ GAP (i any)) <br />Quantity <br />Wt Aid13 <br />X <br />VW <br />P <br />1 <br />181 <br />z <br />W <br />2 <br />3 <br />4 <br />14 SpeW Hard" IrOuctionis and Additional <br />1 t5Ob- � 2 �, Nk <br />15 GENERATOR'SX fEROR'S CERTIFICATM I tereby declare Osat the contents Ovs consgcxnent ere *and a=raWy descnbed above by the paper shipping nacre, and are classified packaged, <br />marked and late#.diplacarded, and are in al respects m proper condition for transport according to apphcaMe international and national governmental regulations O expos stupment and I am the Primary <br />Exporter i ca* that the contents of go consignment conform to the terms of the attached EPA t <br />I the waste rmmmvzabon statement identified m 40 CFR 262 27(a) (d I am a large pity ) or (b) (d I smallra <br />is titre <br />2a re <br />F1M�/2i -- I , <br />16 Intemabonal Shipments <br />[31.pbttA S ❑ Export konr Port of enlrylazd <br />ear <br />1b <br />. r <br />Trsrspler signature tor eVorts ord Date leaving U S <br />17 TramporterAckn nt of Rempt of <br />r er i <br />� <br />y <br />CL <br />Wz14111 <br />tem "� <br />' <br />C <br />QTransporter <br />2 PnnWiflypied Name Sigrnituro <br />Month <br />18 Discrepancy <br />We Dtsompency Indication Space ® Quanbty ❑Type L_l Rescdue <br />❑ Partial Rejection <br />❑Ful Relectan <br />Manifest Reference Number <br />18b Alarnate Faaldy (or Generator) <br />US EPA ID Number <br />U <br />W <br />fad!s Phone <br />18c Sgnahae of Altemate FacMty(orGenerator) <br />Month Day Year <br />S2 <br />19 Hazardous Waste Report Management Method Codes (c e, codes for hazardous waste treatrrumd disposal, and recycling systems) <br />0 <br />1 <br />2 <br />3 <br />4 <br />20 Designated Fatality Oamo or Operator Certification of recampt of hazardous matianals domed by the mantles! except as noted in Rem 18a <br />n yped Norma Signatu <br />Month Day Year <br />L <br />Ivy AA-CAt1r,- I " <br />L <br />I I I <br />EPA Form 8700-22 (Rev 3-05) Previous eddions are obsolete DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />