COMPLIANCE INFO_2020 - Laserfiche WebLink

Home Browse Search

Please print or type. I Form Approved.OMB No.2050-0039 UNIFORM HAZARDAWS, 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST . t;,r ;kyr, ; J 1 w&7F&7z2o- 1 014705942 FLE 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) Alf in E;e,-_tRS!'iit;.i ko: 199 FrarkL V*st Sted-tan, CA P52Do Generator's Phone: 20# 716 6.Transporter 1 Company Name U.S.EPA ID Number Aatvene,��Ch"ki Tr . -fit kv ,r, L k r- 7.Transporter 2 Company Name U.S.EPA ID Number 6 SYN – U.S.EPA'[OF Ndmb& US EcAbvw Bt>« i1 miles a Bell NV73=0= Facility's Phvne: 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./Vol. 0 X Nx*m Hy*cpw�ie,Passmim 14*0111 },8,PGffi 2, � 7/ P int I MM[70x7 Owl W 0 X era>Ioie, ti o s. ). 1 P 1 DOd w 9,PG9 ! 323 �@0 3 ,moat:. , 172! OM4 cow Dmf ).e.Pct `m 1Y7 P 0= onto 4. 14.Special Handling Instructions and Additional Information Pli r4X71W 24111119D 'I)ER14Rte' i:; - $�8fC77fi: d1�l2llf=f6713► .�.. �m-S . 0 2)ERM71; 0701 122@ Al 15. GENERATOR'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 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)(if I am a I quantity generator)is true. er rator'sl0fferor'/s PP/)rintedffyped Name ignature Month Da Year N 16.Inte ational Shipmer F Import to U.S. ❑Export from U.S. Port of entry/exit: ? Transporter signature(for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials I— Trans rrterr 1 Printed/Typed me Si nature Year �,j/x� O 1[��' J40 9 M rah y 4W a d,�/ Z Transporter 2 Printed/Typed Name Signature Month Day Year 18.Discrepancy t Ba Dmerepency[ndicalion Space U Quantity ❑T p pe 0 Residue Y :- . .�:.k,.:.._�'•N,�1:G1"'y'ani._ OFul�i�' rJn v Manifest Refeience NumWr F 18b.Alternate Facility(or Generator) U.S.EPA ID Number _J V LL Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z S2 19.Hagrdou Waste Report Management Method Codes '.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU 1. . 2.. t i 3. 4. 20.DesignateT Facility Owner or Operator-Certification of receipt of hazardous materials covered by the manifest exce as 6ted in Ism 18a P,intedfrypedName i + Signature �� Month Day Year EPA Form 8700-22(Rev.12-17) Previous editiffidare obsolete. DESIGNATED FACILITYTO GENERATOR