COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

l Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No, 2050-0039. UNIFORM HAZARDOUS 1 , Generator 1) Numpyyer /� 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number ' p WASTE MANIFEST C '92 6100 06'579 ® ��"7 ��®® 012177799 JJ 5. Generato 's Name and Mailing Address Generatots Site Address (if different than mailing address) (Aiewliek 6. Tmnspoder 7 Company Name U.S. EPA ID Number 7, Transporter 2 Company Name U.S. EPAIDNumber B. Design ted acilityName and SiteAddr ss U.S. EPA ID Number Facility' Phony 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit HM and Packing }Group Qf aany)) �,q,� g� {r/g }� No. Type Quantity W\tJV01. 13. Waste Codes C3 1. �y"� 4s ��S e"I1�U/ e..j 5J R®�V® / � 20 d w 2. 0 4. tA. Special Handling lnsWctions andAdditional nforma5on 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents cliffs consignment are fully and accurately described above by the propershipping name, and are classified, packaged, marked and labeled/placarded, and are in all respects In proper condition for transport according to applicable International and national governments] regulations. If export shipment and I am the Primary Exporter, I codify that the contents of this consignment conform to the terms of the attached EPAAcknowledgmenl of Consent I certify that the waste minlmizatlon stale entlde . ilfed In 40 FR 26227(a) (if i am a large quantity generator) or (b) (ifI am a small quan8ty genera GenemtofsfOffero 'n(e yped Name Slgnatur Month Day Ye J 16. International Shipments r ❑ Import to U.S. - ❑ Export from U.S. Port of en exit: Z Transporter signature (for exports only); Date leaving U.S.; j �= 17. TranspoderAcknowledgment of Receipt of Materials Tran er 1 Printed/typed Name Sign Month Day Yi o� /j71 A zQ Transtilkon2 PjJNiryped Name Signahalf or Month Day Year 18. Discrepancy Its. Discrepancy Indication Space ❑ Quantity []Type ❑ Residue ❑ Partial Rejection El Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number '.. j U uG- Facility's Phone: '.. w 18c, Stgnature ofAltemale Facility (or Generator) Month Day Year R z N19. Hazardous Waste Report Management Method Codes Its., codes for hazardous waste treatment, disposal, and recycling systems) 2. 3. 4. ' 20. Designated Facility Owner or Operator: Cor itication of receipt of hazardous materials covered by the manifest except as need in Item 18a Prntedfryped Name Signal re Month Day Year irk W� 101111II & EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete, DESIGMATED FACIL T59 TO DESTONAT O®N STATE (OF REQUIRED)