COMPLIANCE INFO - Laserfiche WebLink

Home Browse Search

Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) Form Approved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. UNIFORM HAZARDOUS 1, Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number - WASTE MANIFEST 1 tF ; .PFLE 5. Generators Name and Mailing Address Generators Site Address (f different than mailing address) Generators Phone. 6. Transporter 1 Company Name U.S. EPA ID Number 7. Transporter 2 Company Name U.S. EPA ID Number 8. 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 13. Waste Codes No, Type HM and Packing Group (if any)) Quantity WtJVol. 1. —` Z 2. t Uj ) 3. I c 4. 3 14. Special Handling Instructions and Additional Information 15. GENERATOR'SIOFFEROR'S CERTIFICATION: 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 labeled/placarded, and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if t am a small quantity generator) is true. Generators eroes Pdnted(fyped Name tgna re Month ga—y: Year - 16. International Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: Transporter signature (for exports only): Date leavi U.S.: W 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name gnature on ay ear nom, Q Transporter 2 Printed/Typed Name Signature Month Day Year cc 18, Discrepancy 18a. Discrepancy Indication Space ❑ QuantiT Residue ty ype Partial Rejection El Full Rection Manifest Reference Number: 18b, Alternate Facility (or Generator) U.S. EPA ID Number J V Q Facil' s Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year Z U) 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) LLJ® 1. 2. 3. 4. 20. Designated Facility Owner or Operates: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete.