Laserfiche WebLink
Please print or type. Form Approved. OMB No, 2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2. Page703, Emergency Response Phone 4. Manifest Tracking Number <br /> WASTE MANIFEST bq <br /> 5, Generators Name and Mailing Address Generators Site Address (if different than mailing address) <br /> k `J D �sy <br /> l_)DI GAs <br /> Generator's Phone„ <br /> 6, Transporter 1 Company tame" ` U.S. EPA ID Number <br /> E . ;�.. <br /> 7, Transporter 2 Company Name U S. EPA D Number <br /> LM <br /> 8. Designated Facility Name and Site Address U.S. EPA ID Number <br /> . yC HM K ," f Sir idz p`s•,.Et ia ', . <br /> Facility's Phone.'-; i s t <br /> 98 9b. U .S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11 . Total 12. Unit 13, Waste Codes <br /> HM and Packing Group (if any)) No. Type Quantity Wt.Nol. <br /> 11 <br /> t i sit . _K3i t, • Na, f, . .' e t ., 4� f + 1 I f qtr . } .`-1 , y F, . •s .P. r f » <br /> C U'i 1' l ( 111 • ._ _ ` fi t <br /> Z 2• <br /> LLJ <br /> R1 C F MOD <br /> 3. <br /> S _ P Z V. 20i9 <br /> 4• N V I RO IN IIEN YAC 1-1 A <br /> 1 ) [' PAR NIEN <br /> 14, Special Handling Instructions and Additional InformationAl <br /> JLUT- <br /> t .s . is.:I l .s t , Ita�.. . .;,s .�t _ E44 '%I€,. I` [ ' rir "..I_ . <br /> A f. s ..,m f E"", <br /> 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, <br /> 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 <br /> Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> 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. MP <br /> Generators/Offerors Printedf.Typed Name Y a Signature Month Day Year <br /> 16. Inter tional Shipments <br /> >— ❑ Import to U.S. ❑ Export from U .S. Port of entrylexit: <br /> Transporter signature (for exports only): Date leaving U.S.: <br /> Ce 17. TransporterAcknowledgment of Receipt of Materials <br /> UJ <br /> Transporter 1 Printed/Typed Name" f Signature "" Month Day Year <br /> CL <br /> Cl) <br /> Transporter Prete /Type Name Signature Month Day Yea <br /> ( ! a <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space quantity4 El Type El Residue El Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18b, Alternate Facility (or Generator) U.S. EPA ID Number <br /> V <br /> W Facility's Phone: <br /> W 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> Q <br /> 19. Hazardous Waste Report Management Method Codes (Le. , codes for hazardous waste treatment, disposal, and recycling systems) <br /> ® 1 2• 3, 4. <br /> 20`06signatedsFacility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedffyped,Narrre Signalurp _ t J on Day Yea <br /> ( / M th r <br /> EPA Form 8700.22 (Rev. 12-17) Previous edition are obsolete. DESIGN4 <br />