Laserfiche WebLink
:d: (Forrrl,designed for use on elite (12 -pitch) typewriter.) <br />.A HAZARDOUS 1. Generator ID Number <br />,STE MANIFEST GAI-v b45* 14 <br />denerator's Name and Mailing Address <br />14o, iY 1' Acf 1 h i <br />411 1NOUSTRIlest. A't <br />�`t I ON c: ri 955366 <br />Generators Phone: 209--699-6118 <br />6. Trarisporle(1.Company,N Tef 1._AI €?tl[.i> <br />Form Approved. OMB No. 2050-0039 <br />of 3. Emorggrgy Response Phone 14, MaIf Tr eking Number <br />8. Designated Facility Name a. d Site Address U.S. EPA IA Number <br />r t,lF I C tit"NRCI• Rt COVERY <br />51W EAST PICO Fit_VQ- <br />I OS ANGEI-ES, CA 9W023 <br />(f3tt 0) 499-7.14x. <br />Facility's Phone: <br />ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11. Total 12. Unit <br />HM and Packing Group (if any)) 13. Waste Codes <br />No. Type Quantity Wt.Nol. <br />� "` (, i _I Fri:? , (Iii 1 ) .• <br />Z Vol" <br />LLI <br />t3iPk F�F�r-1� tbi IE}AI }- t E Ak, If He?td # A fikE (ik k A i f f } - _. <br />3. <br />4. <br />14. $ ecial (ion li st cos. ndA dit'o al I do <br />61 tt E �x4)ta+�rL��a � PROTECTIVE i 7�1F. i t 0TPd1 N(; 41W, EMIFIRG NCY CONTACT. KIRK WA f 0RF <br />"'R( <br />-14 : 9bl) '128 914;t li <br />fnAHFi t=" k IRTf'P 'I PFiON( 4 '1_8Rf.-'3 770--s15 <br />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, <br />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 <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if 1 am a small quantity generator) is true. <br />Generators/Offeror's Printed/Typed Name Signature Month Day .' ,Year <br />j 16. International Shipments <br />1 ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br />Z Transporter signature (for exports only): Date leaving U.S.: <br />w 17. Transporter Acknowledgment of Receipt otmaterials <br />Transporter Printed/TypedName Signature Month pay i Year - <br />0 <br />a- <br />rn <br />Z Transporter 2 Printedrryped Name Signature Month Day Year <br />18, Discrepancy <br />18a. Discrepancy Indication Space <br />Quantity 1:1 Type El Residue <br />Manifest Refe <br />18b. Alternate Facility (or Generator) <br />L) <br />LL Facility's Phone: <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />2. <br />7- <br />20. <br />Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />PnntedrTyped Name Signature <br />❑ Partial Rejection <br />U.S. EPA ID Number <br />4. <br />❑ Full Rejection <br />Year <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />