COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

tali 44 k p Please print or type.(Form designed for use on elite(12-pitch)typewriter,) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Maoilest Tracking Number (� WASTE MANIFEST t:f31,H04►4: 33Fs =t= 's. >' 4 0'8 6�" T - V KS 5.Generators Nave and Mailing Address Generator's Site Andress(if dif miril than mailing address) �+t11 }E1^riA!ttZ� ',ervice5 1400 E Roth fid Generators Phone. B.Transporter 1 Company Name U.S.EPA ID Number SAFEXY-KLEEN SV9TEMS, INC. TXRWII1285 1.TranspolrW2 Company NNW U.S.EPA ID Number 8.Designated Facility Name and Site Address Ti' RM0 FLUIDS M U.S.EPA ID Number 4301 W JEFFERSON ST RHLiiE:�f T?[ , Al (�zR1k3 X00. 3`�®--7`165 ". Facili '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 HM and Packing Group(if any)) No. Type Quantity Wt.Nol. rr 1. N N-RCRA miAnouS WAa rF soup � DM r 13RAIldE-D f 1N[314AWD LiF;FI] 6%t- FILTERS) Z 2, 0 3. 4- ';pscial Handling ftlrudions and Additional Information r, CS i 11fti rd[.- oi(;1r' 01 -800--468 117160 (!;K 1 TF f V4 Inf-I 1 rn I T , i F--RQ QS - tYr v 15. GENERATOR'SIOFFEROR'S CERTIFICATION,. I hereby declare that the contents of this consignment are fully and a=ra*described above by the proper sgippfng name,and are classf8ed,packaged, marked and labeled/placarded,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,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 I am a small quantity generator)is true. GenerataralOtfemes PrinteWyped Name S ginalure Manlh Day Year -J 16.International Shipments z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(f6r exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed(Typed Name Month Day Year O Transporter 2 PnntedlTyped Name Signaturra Month ++Day Year 18 Discrepancy } 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number-, F 18b,Alternate Facility for Generator) U.S.EPA ID Number J V 1a, Facililys Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) C 1_ 2. 3, 4. 14—?) 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PnnlerhTyped Name Signature r Month Day Year EPA Form 8700-22(Rev.3-0) Previous editions are obsolete. DESIIGNAFEII FACILITY'S COFY I) ?07:'&76/ 156 33