COMPLIANCE INFO_2018 - Laserfiche WebLink

Home Browse Search

Please print or type. Form Approved. OMB No. 2050-0039 UNIFORM HAZARDOUS 1 . Generator 10 Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST C" 6 F L E 6. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) Iffy LLC 8111%yr . , . . StXktbnCA 95 Generator's Phone : 6, Transporter 1 Company Name U.S. EPA ID Number Advanced CheWcal Trampait Ino . /DBA a I A 0 7. Transporter 2 Company Name U.S. EPA ID Number VVoddvvkW Recomy SyatBrRIm CAR000175422 8. Designated Facility Name and Site Address U.S. EPA ID Number Yum Y , ILC 2730 E . 1 3th St AZR00051 %24 Yumq� AZ 85M Facility's Phone: .S 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 . Total 12, Unit HM and Packing Group (if any)) No. Type Quantity Wt ivol. 13. Waste Codes iglNonRCCA Hazaidous Waste Sohd (ink Caftfldges) P 3520 Uj '.omit A Hazardous Waste, Solkit (Ott ds) DIM q P 3. 4 14, Special Handling Instructions and Additional Information FMCd f ) 1812221 1 ) MM IRM 15. GENERATOR'SfOFFEROR'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 labelediplacarded, and are in all respects in proper condition for transport according to applicable intemationaland 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 EPAAcknowledgment 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) (ifI am a small quantity generator) is true. Generatoes/Offerofs PrintedfTyped Name Signature Monti Day y�2j 1 j.j16, IntematonaiShipments Import to U.S. ❑ Export from U.S. Port of entry/exit: ansporter signature (for exports only): Dale leaving U.S.: W 17, Transporter Acknowledgment of Reoeipt of MaterialsLU 7 YPed 1"ameSgpilurHie on Qa1ya lei z Ttansportef 2 Printedrryped Name Signature Month Day Year h 1e. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S, EPA ID Number r� Facility's Phone: H18c. Signature of Alternate Facility (or Generator) Month Day Year Q Z CD 19 Hazardous Waste Report Management Method Codes (is., codes for hazardous waste treatment, disposal, and recycling systems) 1 - 2, 3. 4. 20, Designated Facility Owner or Operator• Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedfTyped Name Signature Month Day Year EPA Form 8700.22 (Rev, IV7) Previous editions are obsolete. GENERATOR'S INITIAL COPY