Laserfiche WebLink
Pleosq..prit)t or.type.(Form designed for use on elite(12-pitch)typewriter,} <br /> Form Approved.OM8 No',2050.0039 <br /> 111101M 1AIA11011 1 1,Generators Numbar 2.Page I of 3.Emorg—oncyResponsD Phone 4.Manifest T k%'Numob <br /> WASTE MANIFESTSKS <br /> 5.Generators Name and Mailing Address 100 2- 3 G'k <br /> GaneratoN Site Address—(Ifdigerent than mailing address) <br /> Generator's Phone; <br /> 6.Transporter-1 Company Name — U.S,EPA ID Number <br /> T.Transporter 2 Company Name <br /> U.S,EPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> U.S.EPA 10 Number <br /> PYT r*i <br /> vq— <br /> Facilily's Phone: <br /> 98, 9b.U.S.DOT Description(including Proper S Ipping Name,Hazard Class,ID Number, 110.Containers 11,Total 12,Unit <br /> HM and Packing Group(it any)) 4.Waste Codes <br /> No, TYPO QuantityWLIVOL <br /> 0 <br /> Uj <br /> 3. <br /> 4. <br /> 1-4Speclal Handling Instructions andAdditional In I form Win <br /> rj! <br /> 1P C, Pi-- 7A,."01 r..,H <br /> 15, 'GENERATOR'S/r5pF�Rb 'S rtµ ydia a t1h` <br /> W fild, <br /> IrIFICA rat 6 be trit�NtUly;!—Y ' tppl,,g name,arx!are classified,packaged, <br /> ,.11 <br /> marked and labefed/placarded,and are in aspects In proper condition for transport according to applicable International and national governmental regulations,If expel shipment and I am the primary <br /> Exporter,I cerfily that the contents Of this con�lgn ant conform to the terms of the attached EIIA Acknowledgment of Consent, <br /> A�ertily that the viaStemInimization slatemeniIden jified In 40 CFR 262.27(a)(III am large quantity generator)or(b)(Ill a <br /> ., <br /> TonerOes/Offerot'sP(ln(odfrypedNamoI J, Signature <br /> Month <br /> 16,International shipments F] <br /> Import to u's ❑Export from u's, P0,1 ofenlry/eyft- <br /> Transporter signature(for exports only):. ------------ <br /> bate leaving U'S,: <br /> 17.TtansporterAcknowledgment of Receipt of Mate Is <br /> 0 TranspoftgW Pfintedfryped Nana--- Signature Month Day Year <br /> (n <br /> Z TranspoAdF 2 PriRedtTypbd'NA0a, Signature <br /> Month Day: Year <br /> L I <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El Quarity El Type F]Residue ❑Partial Rejection ❑Full ReJ,,flon <br /> 18b,Alternate Facitily(or Generator) Manifest Reference Number: <br /> U.S.EPA ID Number <br /> Facility's Phone; <br /> 78—c Signature ofAllemate Facility lot—Goneralor) <br /> Month Day Year <br /> 19.Hazardous Waste Report Management Method(odesi,(Le.,codes for hazardous waste treatment,disposal,and recycilng systems) <br /> 4: <br /> 20.Designated Facility Owner otOperator,Cerilricat n of receipt of hazardous materials covered by the manifest except as noted in Own itia <br /> Ptintedfryped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3.05) Previous editions aa obsolete. <br /> GENERATOR'S INITIAL'COPY <br />