COMPLIANCE INFO_2021 - Laserfiche WebLink

Home Browse Search

Please print or type-(Form designed for use fix elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS I.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.ManNest Tracking Number WASTE MANIFEST018681 J J K 5,Generator's Name and Mailing Address 3 Generator's Site Address(if different than mailing address) Gmeratads Phone: 6.Transporter 1 Company Name ll.5:EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Fadtity Name and Site Address U.S.EPA ID Number Facility's Phone; ga. 91b•US,OCT Description(including Proper Shipping Name,llaZard Class,I©Numher, 10.Containers 11-Total 12.Unit HM and Packing Group(If any)) No. Type Quantity Wwol. 13-Waste Codes 1. O 3— nu,t Z Z. c� 3. a 14.Special Handling Instructions and Additional Information 15. GENERATOR'SiOFPEROR'S CERTIFICATION:1 hereby declare ttiat the contents of this consignment are fully and accurately described above by the proper shipping name,and are classlAed,packaged, marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable intemational and naWnai governmental regulations.If export shipment and 1 am the Primary Exporter,I certify that the contents of Ibis 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)(tit t am a large quantity generator)or(b)(dI am a small quantity generator)is true. GenaratorslO€fernrs Pwtad yped Name Signature MOntb Day Year 16.International Shipments ❑Import to U-S. Export from U-S. Port of entrylexrl: _ Transporter signature(for exports only): Date leaving U.S.: 17.TransporterAclvmvtedgment of Receipt or Materials LU M Transporter 1 Nnte&Typed Name Signature Month clay Year d rn 2 Transporter 2 PriatedlTyped Name Signature Month Day Year arc t- 18.Discrepancy 1Be.Discrepancy Indication Space ❑ Lluantity ❑Type ❑Residue ❑Partisl Rejection ❑Full Rejection 18b.Alternate Facility RaWence Number:lity(or Generator] U-S-EPA ID Number J U Fad Vs Phone: 16c.Signature of Aftamate Facility(or Generator) Month Year Q +9.flaxardous Waste Report Managernent Method Codes(I.e.,codes for hazardous waste n'eatmant,disposal,and recycling systems) 2. 3. 4. 20.Designated Facility Owner or Operator.Cerlificaton of receipt of hazardous materials covered by the manifest except as noted in Item 1B Printedfryped Name • r Signature Month Day Year EPA Farm 8700-22(Rev.3-05) Previous editions are obsidete. TRANSPORTER'S COPY