Laserfiche WebLink
Please print or <br />ed for use on elite (1 pi h) typewriter.) � :�' "" ' <br />I. Generator ID Num 2. Page 1 of 3. Emergency Resp <br />f <br />Address Generator s Site Add <br />8. Designated Facility Name and Site Address i r <br />Facility's Phone: t` . <br />ya 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />HM and Packing Group (if any)) <br />0 <br />Z 2• <br />LU <br />C7 <br />4. <br />14. Special Handling Instructions and Additional Information <br />0 <br />Phone <br />10. Containers <br />No. <br />Form Approved. OMB No. 2050-0039 <br />nq Number <br />iLi' FL <br />U.S. EPA ID Number <br />r� <br />U.S. EPA ID Number <br />Number <br />E <br />12. Unit 13. Waste Codes <br />Wt.Nol. <br />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, <br />for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br />marked and labeled/placarded, and are in all respects in proper condition <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I large or (b) (if I am a small quantity generator) is true. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if am a quantity generator) <br />Month Day Year <br />Generator's/Offeror's Printed ped Name qna re <br />J <br />16. Intemational Shipments ❑ Export from U.S. Port of entry/exit: <br />❑ Import to U.S. p° <br />Z <br />Transporter signature for exports only):Date leaving U.S.: <br />17. Transporter Acknowledgment of Receipt of Materials on ay ear <br />ignature <br />Transporter 1 Printed/Typed Name <br />O <br />ap <br />. <br />9 Mon ay ear <br />rited/Typed Name i nature <br />Transorte2r Pn <br />18. Discrepancy <br />18a. Discrepancy Indication Space Quantity ❑Type ❑ Residue ❑ Partial Rejection Full Rejection <br />❑ <br />Manifest Reference Number. <br />U.S. EPA ID Number <br />18b. Alternate Facility (or Generator) <br />J <br />G <br />I <br />Facility's Phone: Month Day Year <br />w <br />18c. Signature of Alternate Facility (or Generator) <br />a <br />z <br />N19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />UJ <br />1 2. 3. 4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a MonthDay Year <br />Pnnted/Typed Name Signature <br />GENERATOR'S INITIAL COPY <br />Form 8700-22 (Rev. 3-05) Previous editions are obsolete. <br />EPA <br />