Attachment 18_Example Uniform Hazardous Waste Manifest_Belgium Netherlands_Contract Renewal_24-BE-200_v2Oct24.pdf
PDF 25 KB Posted
- Solicitation number
- SP450025R0009
- Issued by
-
Defense Logistics Agency
About this file
This is a blank Uniform Hazardous Waste Manifest form (EPA Form 8700-22, Rev. 12-17) used for tracking hazardous waste shipments. The form includes fields for documenting generator information, transporter details, designated facility information, waste descriptions, quantities, container types, and special handling instructions. It contains sections for various certifications and signatures, including generator/offeror certification, transporter acknowledgment, and facility owner/operator certification. The form also includes spaces for international shipment information and discrepancy reporting.
This template appears to be an attachment for contract SP450025R0009, which involves hazardous waste removal and disposal services in Belgium, Netherlands, and Germany. The form demonstrates the type of documentation that will be required for tracking hazardous waste shipments under the contract. The document is marked as "Attachment 18" and includes "Belgium Netherlands" in its filename, indicating it serves as an example manifest for international waste shipments in these regions.
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Text version
Please print or type. Form Approved. OMB No. 2050-0039
UNIFORM HAZARDOUS
WASTE MANIFEST
1. Generator ID
Number
2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number
5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address)
Generator's Phone:
6. Transporter 1 Company Name U.S. EPA ID Number
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:
9a.
HM
9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, and Packing Group (if any))
1.
2.
3.
4.
10. Containers No. Type
11. Total Quantity
12. Unit 13. Waste Codes Wt./Vol.
14. Special Handling Instructions and Additional Information
15. GENERATOR’S/OFFEROR’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 EPA Acknowledgment 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 I am a small quantity generator) is true.
Generator's/Offeror's Printed/Typed Name Signature Month Day Year
16. International Shipments Import to U.S. Export from U.S. Port of entry/exit:
Transporter signature (for exports only): Date leaving U.S.:
17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year
Transporter 2 Printed/Typed Name Signature Month Day Year
18. Discrepancy
18a. Discrepancy Indication Space Quantity Type
Residue
Partial Rejection
Full Rejection
18b. Alternate Facility (or Generator) Manifest Reference Number:
U.S. EPA ID Number
Facility's Phone:
18c. Signature of Alternate Facility (or Generator) Month Day Year
119. . Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
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 Printed/Typed Name Signature Month Day Year
EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM
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| Please print or type. Form Approved. OMB No. 2050-0039 |
| EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. |
File details come from the government source that posted it. Updated .