COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

IIII III II IIIII I IIIII�;:'l""'.I 111111 II Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.7agel3.,Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST , i 004510985 FLE 1 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Generator's Phone: 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 a't ar; i U.S.EPA ID Number Facility's Phone: 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)) 13.Waste Codes No. Type Quantity Wt.Nol. �: .t, 1,f ft'i�filVlt r , ,,,, i 0 ,. t W 14.Special Handling Instructions and Additional Information 15, GEN ERATOR'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, 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 EPA Acknowledgment 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)(if I am a small quantity generator)is true. Generator' ffero s rinte yped Name igna ure on F Da—y--Te—ar -+ 16.International Shipments I-- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Z Transporter signature for exports only): - Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed NameSignature onl ay Year rn I L I. Q Transporter 2 Printed/Typed NameSignature Month Day Year 1 H 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type �Residue ❑Partial Rejection ❑Full Rejection 14A/VManifest Reference Number: 18b.Alternate Facility(or Generator) 2alf if U.S.EPA ID Number u- Facility's Phone: 1(` W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z n19.Hazardous Waste Report Management Method Codes(i.e.,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 Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.3 Q5)t Ar09'o editions are obtsglete,. tt1:. .?�k?.;}}:� +r..;I , ,q;;.gFY4RATgR'S INITIAL•ceRy