COMPLIANCE INFO_2022 - Laserfiche WebLink

Home Browse Search

RECEIVED ON 4/5/2022 VIA EMAIL to-i" Please print or type. Form Approved,OMB No.2050-003: UNIFORM HAZARDOUS 1.Generator ID Number 12,Page 1 of 3.Emergency Response Phone 4 Manifest Tracking Number WASTE MANIFEST , SKS 5,Generators Name and Mailing 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 a 8.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: - 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)) No. Type Quantity wt./Vol. 13.UVaste Codes 2. LLJ ` 3 i 4.. - - 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 labeledtpiacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regula+tons.If export shipment and I am the Primary Exporter,l 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 GFR 262,27(a)(if i am a large quantity generator)or(b)(if I am a small quantity generator)is true Generators/Offeror's P€inted;D'yped Name Signature =N Month Day Year 1 ,_,r 16.International Shipments El lt��ii Import to U.S. ❑Export from U.S. Port of entrylexit: Transporter signature(for exports only): Date leaving U.B.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 FrintedfTyped Name Signature Month Day Year JIL eZq Transpoder 2 Printed/Typed Name Signature Month Day Year LK r- 18.Discrepancy 1Be.Discrepancy Indication Space ❑ Quantity, ❑Type ❑Residue ❑Partial Rejection Full Rejection f Manifest Reference Number: 18b,Alternate Facility(or Generator) U.S.EPA ID Number IIC3 5 Facility's Phone: tLaa 18c.Signature of Alternate Facility(or Generator) Month Day Year Z A19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1 2. 3. 4. 20.Designated FacilityOwner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item Ise i PrintediTyped Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COM