CO0046829 - 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 li JJ K 5 Generator's Name and Mailing Address Generators Site Address(if different than mailing address) Generators Phone: 6.Transporter 1 Company Name U.S.EPA 0 Number jo 7 Transporter 2 Company Name U.S.EPA ID Number 8.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, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes a w Z 2. LL; c� 1 �S, Ij 1i 3. 4. i ' ) 14.Special Handling Instructions and Additional Information 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 EPAAcknowledgmenl 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]am a small quantity generator)is true. GeneralorslOfferoes Pnnted/Typed Name Signature Month Day Year 1xf -+ 16.International Shipments Z ❑Import t0 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 Transporter 1 Printed/Typed Name Signature Month Day Year O a Z Transporter 2 Printed/Typed Name Signature Month Day Year d' F- 18.Discrepancy 1Ba.Discrepancy Indication Space ❑ Quantity Type 1:1Residue El Partial Rejection ❑Full Rejection Manifest Reference Number, 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ V W Faciliy's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z O 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment.disposal,and recycling systems) N 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 Pnntedayped Name Signature Month Day Year EPA Form 8700.22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY