COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

�� .. ' N Please print or type. (Form designed for use on elite. (12-pitch) typewriter.) E D Form Approved. OMB No. 2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number a rogel3 mejgency Response Phone 4. Manifest Tracking Number �[ WASTE MANIFEST q :.a ° t f rr JJ K 5. Generator's Name and Mailing Address ne to Sia MRS (if different than mailing address) ' NVIRO MENTAL HEALTH Generator's Phone .>>.. ' t > i .- , 6. Transporter 1 Company Name — U.S. EPA ID Number 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address - U;S. EPA ID Number � ,:+• . .. - . Al Facility's Phone: 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./Vof. . � At -. ^' sirE i. T31e _C UJ 2. 3. 4 I ! 14. Special Handling Instructions and Additional Information ' `j t aA. r ; r f r • ,,- ma . n f .� ; rAll 15. GENERATOR11OFFEROWS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, ard are. classified, packaged, 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowiedgment of Consent I certify that the waste minimization statement identified in 40 CFR 262.27(a) (it I am a large quantity generator) or (b) (if i am a small quantity generator) is true. Generatoes108eror's Printed/Typed Name Signature Month( Day Year l t t 16. International Shipments Plot ❑ Import to U.S. ❑ Export from U.S. Port,of entry/exit: Z Transporter signature (for exports only): Date leaving U.S.: w 17. TranspoderAcknovAedgment of Receipt of Materials Transporter i PrintedlTypad Name i Signature r' ' Month Day Year i1 yy r / All, J C rnsplder ' ... `' 9 2P nted/Typed Name Signature ` " Month Day Year 18. Discrepancy 18a. Discrepancy Indication Space F Quantity ❑ Type ❑ Residuej El Full Rejection ❑ Partial Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number _J V iQ Facility's Phone: W 18c. Signature of Altemate Facility (or Generator) Month Day Year Q N19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) W 1 21 3. A 4. 'r 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pri�tedlTyped Name f 1 Signature r � r Month Day Year EPA Fdrrn 8700-22 (Rev. 3.05) Previous editrons` are obsolete. DESIGNATED FACILITY'S COPY i • C I