COMPLIANCE INFO_2020 - Laserfiche WebLink

Home Browse Search

Please print or type. I Form Approved.OMB No-2050-0039 UNIFORM HAZARDOUS 1•Generator ID Number 2.Page 1 of 3.Emergency Response Ptrone 4.Manifest Tracking Humber WASTE{MANIFEST3F;55.c)40 FLE 5.Generators Name and Me Zing Address Generators Site Address(if different than mailing address) Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name _ U-S.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class.ID Number, 30.Containers 11.Total 12.Unit` 13.Waste Codes HM and Packing Group(if any)] No. Type Ouantity WlNol. 1. 4�4 D[ w 2 2. w 3. 4. 14.Special Handling instructions and Additional Information 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and Iabeledlpfacarded,and are in all respects in proper condition for transport according to applicable intemabonal and national governmental regulations.If export shipment and i am the Primary Exporter,I ce thal the contents of this consignment conform to the terms of the attached EPA Ackr•.owledgment of Consent. I certify th waste minimization statement iden 40 CFR 262.27(a)(if I am a large quantity generator) bj(if I am a small quantity generator)is true. Gena ars PrintedrrypejNfne Signatu Month Day Year 6.International Shipments ❑Import to U.S- ❑Ex rom U-S. Port of entry;exit: ? Transporter signature(for exports oniy): Date leaving U.S.: aC 17,Transporter Acknowledgment of Receipt of Materials Ltt Transporter t Printedfryped Name SigVt— Month Day Year CL CL s2 Transporter 2 Printed/Typed Name J_ ignature L j � Month Day Year �, ��G�t.� f�-1 �r may•• � :j '%" 18-Discrepancy 18a.Discrepancy indication Space ❑ Quantity ❑Type ❑Residue Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate f=acility(or Generator) U.S.EPA ID Number C] tai Facifity's Phone: LU 18c Signature of Alternate Facility(or Generator) Month Day Year Q a 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste Ireatment,disposal,and recycling systems) 0 7. if I LP 2. 3- 4. 20.Designated Facility Owner or Operator Certification of receipt of hazardous materiak5 covered by the manifest except as noted in item 1 B PdntedlTyped Name Signature Month Day Year EPA Form 8700.22(Rev.12-W) Previous editions are obsolete. f DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM