COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

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.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST OO DAT 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Wt.tk fI_14 g1 +:iUEY f"...#ilii§; 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 l U.S.EPA ID Number OK tit', Facility's Phone: 9a 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 WtNol. 1. Z 2. LU 3. 4. ENVIR N!'',+ THITA T 14.Special Handling Instructions and Additional Information i Ft�'it SIi�F�lllti� itl�� 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the propershipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemational 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. Generatoes/Offeroes Printed/Typed Name Signature Month Day Year -J 16.International'Shipments " ❑Import to U.S. ❑Export from U.S. Port of entrylexit: Z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day: Year U) '''' ' Month Day Year. Q Transporter 2 Printed/Typed Name Signature l- 18.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 2s* CEM ci Nevada f S LL Facility's Phone: Month Day Year W 18c.Signature of Alternate Facility(or Generator) 4 _ i z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) t)his gefler 0 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 PnntedlTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editionsare obsolete. DESIGNATED FACILITYTO. 'GiENL-2A1i "`