Laserfiche WebLink
Please prim or type. Form Approved.OMB No.20K-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2 Page t of 3.Emergency Response Phone 4.lNarr3fest TreCking Number ��(( <br /> WASTE MANIFEST { J f\ <br /> 5.Generator's Name and Mailing 4ddress Generators She Address(if different than mafing address} <br /> Generator's Phone. <br /> 6 Tfanspoder 1 Company Name U S.EPA 1D Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 5 Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facility's Phone: <br /> 9a 9b.U-S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Conr>er; i1,Total 12.Unit 13.'NaSte Cedes <br /> HM and Packing Group(if any)I No. Type Quantity Wt.rVol. <br /> Lit <br /> 0 <br /> 3 <br /> 1 <br /> 4. <br /> 14.Speaal Handkng instruonns and Additionai information <br /> 15. GENERATOR'WFFEROR'5 CERTIFICATION: I hereby declare that The contents of this consignment are fully and accurately described above by the proper shipping name,and are dassibed,packaged. <br /> marked and labeled?placarded.and are it all respects in proper condition fox transport according to applicable'rnlematienal and national governmental regulations.'(export shipment and l am the Primary <br /> Exparter,I certify that the contents of this consignment conform to the Wmu of the arched EPA Acknowledgment of Consent <br /> - <br /> I certify Mat the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(bl(if l am a small quantity generator)is true. <br /> generator`s Offeror's PdritedlTyped Name signature Month Day Year <br /> i6.International ShipmentsII <br /> F, I�Import in U S. I__i Export from U-S- Port of enlrylexiL <br /> Transporter signature(for exports anty): Date leav+ng U.S.: <br /> tau 17.Transporter Ac}cnowledgment of Receipt of Materials <br /> Im— TranspWer 1 Pantedr'fyped Name Signature Month Day Year <br /> O <br /> a <br /> TranspnRer 2 Pdnted,Typed Name Signature t/ronth Day Year <br /> 1$-Discrepancy <br /> 18a.Discrepancy indication Space r 1 �? <br /> [.....I Quantity �Type �Residue ❑Partial Rejection L—.J Fut!ftejede<sn <br /> Mar9fesT Reference Number: <br /> 'St.Alternate Facility(or Generator} U.S.EPA ID Number <br /> U <br /> Facility's Pnore. <br /> 1�c Signature of Altemale Facility for Generator) Month Day Year <br /> Q <br /> Z <br /> CD 10.Hazardous Waste Report Management Method Codes(i.e.,cedes for hazardous waste treatment,disposal.and recycling systems} <br /> U3 <br /> d 1. 2, 1 4. <br /> 2(t.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in item 18a <br /> Printed! yped Name Signature Month Day Year <br /> EPA Form 8700-22(Ray.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />