COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

Please print or type. (Form designed for use on elite ( 12-pitch) typewriter.) Form Approved . OMB No. 2050.0039 UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST tfA zs4:lt?'.t �fJr��t1 t ?ut i+F''2: :i�2 > t0025711090 G D F 5, Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) El ' Generator's Phone: ; s S E :." 1 ; ilri 6. Transporter 1 Company Name MAR 0 2 Z01b U.S. EPA ID Number IT 7- Transporter 2 Company Name ® jE y S. EPA ID Number NYIRONMENT ng- . TAyMEENJI 8, Designated Facility Name and Site Address I I I U.S. EPA ID Number rIN*' 1 31 i'; :3 Ti. °ltY l 't�3 'IRF k7I 1314 'h� 1F�c6, tuit3 9T =;+t' ftt : 'ls.f? i , i _ _t"kq 6! INI t[ 1s ll y p1° Y Y Facility's Phone: r ; ✓ t§ ,r .<• `,'s;T 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. ' <Nftp' ws ?:a 3!VA47/ fL IF low Z 2. LU O FIT 3. 4. IF 1,4. Special Handling Instructions and Additional Information ,ti , t37 ,,i t' C� # 4 ' IVI. 4a # 1 )tP # p 3,E:1`its`° (*CVl'AC `I ' 1141A UV L )AY 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 ptoper condition for transport according to applicable international and national governmental regulations. If export shipment and 1 am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgmept 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. Generator's/Offerors Printed/Typed Nape Signature Month Day Year r f IF —i 16- International Shipments F- ElImport to U.S. ❑ Export from U.S. Port of entry/exit: Z Transporter signature (for exports only): Date leaving U.S.: w 17:Transporter Acknowledgment of Receipt of Materials i2 Tranror 1 Printedrryped Name Sig ature Month Dai Year a. O r aTransporter 2 Pdntedrryped Name `,,Sjgnature Month Day Year 18. Discrepancy 18a. Discrepancy Indication Space E Quantity TY 4F` pe ❑ Residue El Rejection El Rejection Manifest Reference Number: 418b. Alternate Facility (or Generator) U.S. EPA ID Number MININIK060110 FL rai IF Facility s Phone: + w 18c- Signature of Alternate Facility (or Generator) MonthDay Year Z y19. Hazardous Waste Report Management Method Codes (i.e-, codes for hazardous waste treatment, disposal, and recycling systems) LLJ 14 1 F 21 3. 41 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Notice : State of California requires PrintedRypad Name Signature gernerator to photocopy and mail to DTSC with 30 days : EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. p , 0 BOX 400 IF Sacramento . Cal 95812-0400