COMPLIANCE INFO_2018 - Laserfiche WebLink

Home Browse Search

Please }print or typo . (Fomr designed for use on elite ( 12•pilcll) lypewri(or.) Form Approved, OMB No, 2050.0039 UNIFORM HAZARDOUS Generator ID Number 2. Page 1 of 3 . Emergency Response Phone 4. Manifest Tracking Number WASTE MANIFEST ," " ' 018529473 JJ K 5, Generator's Name and Mailing Address Generators Site Address (if different than mailing address) _ i . .1 A L .. _ .. .. - - .. , J � Generators Phone : G. Transporter 1 Company Name U.S. EPA ID Number , . ' l „ ILf' ! . ' L ' Grs, ( � ( _ A- ._ U 4. , 7. Transporter 2 Company Name U.S. EPA ID Number U.S. EPA ID Number 8. Designated Facility Name and Site Address l '.I i� Cr; L �. F.';rEf1U LG i\ i ci. ' 9058 !\ i) ii <> 0 ) 9 Facilil es Phone: { ) ' 1 '� OQ gat 91b. 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.Nol. 1NON- R (JRA HA%ARDOUS WASTE , SOLID ( BRAKE LATHE SHAVINGS ) g1 o D M I d P AM 2. LU 3: 4. 14 , Special Handling Instructions and Additional Infemration F� MERGENCY CONTACT : CHEMTREC 1-800-424-9300 WOES TERMINAD.: NAERG# 981 : 171 *' PROFILE # 901 : 624141 BRAKE LATHE SHAVINGS * P500-00063210 * APPROPRIATE PPE EQUIPMENT 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the oontantsof this consignment are fully and accurately described above by the propershlpping name, and are classified, packaged, marked and labeled/placarded, and are in all respects in proper•condition for transport according to applicable Inlemalional and national govammental 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 EPAAcknowfodgt of Consent I codify that the waste minimization stator t identified In 40 CFR 62.27(a) (if I am a large quantitygonctaton (b) , Of I am u II quantity g gator) Is o. ane ftcroi s rinladl�yped Name tg ure j Month Day Year .-i 16. International Shipments P— ❑ Import to U.S. ❑ Export from U',S. Port of entrylexit: zTransporter signature (for exports only): Date leaving U.S,: U 17. Transporter Acknowledgment of Receipt ofMaleriais Ce Transported Pri a yped Nam Signature Month Day Year f AZ 71 fil? QTransporter 2 Printed/Typed Nam Signature Month Day Year t - 18. Discrepancy 18a, Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Parisi Rejection ❑ Full Rejection Manifest Reference Number. 18b. Allemate Facility (or Genemtor) U.S. EPA ID Number U rQ+- Facility's Phone: Month Day Year w 18c. Signature of Alternate Facility (or Generator) Q z 19. Hazardous Waste Report Management Method Codes O,e., codes for hazardous waste treatment, disposal, and recycling systems) LL' 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 i Prime yped Name Signature Month Day Year EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITYTO DESTINATION STATE (IF REQUIRED)