COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Farm Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 9.Alanffieat Tracking Number WASTE MANIFEST SKS 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) n`] Generators Phone: 8.Transporter I Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number R.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 Wt1Voi. 13.Waste Codes 1. d isl ' Z 2. W i f.7 3_ i I t i i I 4. 14.Spedal}candling Instructions and Additional Information 15. GENERATOR'SIOFFEROR'S CERTIFICATfON: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and fabeledlplacarded,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,r certify that the contents of this consignment conform to the terms of the attached EPAAcknow#edgment of Consent. I certify,that the waste minimization statement identified in 40 CFR 252.27(a)(if f am a large quantity generator)or(b)(if I am a smalE quantity generator)is true. GeneratorslOfferors PrintedfTyped Name Signature Month Day Year .J 16.International Shipments ❑Impart to U.S. []Export from U.S. Port of entrylexik a Transporter signature(for exports only): Date leaning U.S.: W 17.TransporlerAckaowledgmenl of Receipt of Materials Transporter 1 Pdntedfryped Name Signature Month Day Year O Q Transporter 2 Pdntedlryped Narne Signature Month bay Year F- 18.Discrepancy 18a,Discrepancy Indication Space ❑ Quanti ty ❑Type ❑Residue ❑Partial Rejection ❑Ful!Rejection Manifest Reference Number. 1 Bb.Alternate Facility for Generator) U.S.EPA 1D Number U +ar- Facility's Phone: LU 18c.Signature ofAllernate Facility(or Generator) Month Day Year a z W19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recyding systems) O 1 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Ba PrintedlTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR