Laserfiche WebLink
Please print or type. Form designed for use on elite(12-pitch)typewnter.) Form <br /> Approved.OMB No.205011039 <br /> UNIFORM HAZARDOUS 1,Generate IO Number 2.Page 1 or 3.Emergency ResPoroe phone a.Manifest Tracking Number 7 <br /> WASTE MANIFEST CAD98100126 1 559-997-0107 0 0 0 3 61 1 9 0 G B F <br /> 5.General Name and MeiligOddress Generators Site Address('d ddferem than mating address) <br /> HOT TANK SUPPLY COMPANY <br /> 10398 Z SIERRA 5694 K CLINTON <br /> CLAVIS.CA 93619.9311 FRESNO,CA 93771 <br /> Germramh phone: i - -0109 <br /> 8.Transporter 1 Company Name US EPAID Number <br /> HOT TANK SUPPLY COMPANY CAD981690126 <br /> 7.Transporter Company Name U.S.EPA 10 Number <br /> e.Designated Facility Name and Site Address CHEMICAL WASTE MANAGEMENT,INC U.S.EPA ID Number <br /> 35751 OLD SKYLINE RD. CAT000646117 <br /> KRTTLEMAN CITY,CA 93739 <br /> Fal Phone: 559.3964711 <br /> 9a. St.U.S.DOT Descriptor,(in ludkV Proper Shipping Nacre,Hazanl Clan,ID Number, 10.Call ps <br /> HM and Pal Group(d any)) 11.Total 12,Unit 13.Wale Caries <br /> Ne. Type Owntity NA.Nd. -s=s <br /> c N. <br /> 1. RQ,HAZARDOUS WASTE,LIQUIDt O.S 451 D006 D007 <br /> 92 (METAL'ON LAMINATED SLUDGE)(D006,D007,D008) p2 DM � P <br /> z 2. <br /> � a�^-^^nnn_,�,nc���tm+ nemr narAutr vnc <br /> Vl <br /> 3. <br /> a. <br /> T-7 <br /> 14paclw Handling s and Additional Inforation <br /> . ; 7 9x1.FRG64531CgnwtidsedLoadlAquwnsAlkBineQvanCgm aSgditmLLydlomde3Meds <br /> t_ Mir lmtrte Sldn Wee Proteahe Equipment Gogles and Gloves CWM Plofam EM99 <br /> 9a7.RRGt14onsolkined LoadfAgI MUS Bid SIUdge Conti&E Sodium Hydmmde&MOWS. <br /> Kill knit"Stan eu Pro 'a <br /> 15. GENERATOR'&OFFEROR'S CERTRICATION: I hereby dedare that the contents of this consignment are felly and amumlely deambed above by the proper shipping new,and are classified,pedow, <br /> marked and labeledlplacaNed,and are in all respells in proper corMaon for transport according m applicable international and re0onal governmental regulations.If export shpment and I am the Primary <br /> Exporter,I carl that the contemn of this consgnmml oradorm b bre terns N the aNadsd EPAAcknowtedgmenl of Con l <br /> I certify that the wase mkdrtiratign statement idernified in 40 CFR 21(if I am a lags Quantity generator)or(b)(if I am a small quantity geremtor)is true. <br /> GeneratorslDife pes PnntedlTyped Name Soul1 - MonM Day Year y <br /> LSA. oa a N 09 <br /> v e N <br /> F <br /> 16.International Shipments ❑Import to US. ❑Export from U.S. Pon of enuylel ) <br /> Transporter sgnatUM(far exports onry): Date leavng U.S.: <br /> 17.Transix"Adawmadgmem of Reoapt of Materials �1 <br /> Transportpl Pnntedlfyped Name Sgnztu�m /� Month Day Year <br /> N <br /> RuaN it <br /> Transpater2PdntMlTyped Name Signature Month Day Year <br /> F <br /> 16.Disrrepamy <br /> t tea.Discrepancy Indimtion Space ❑ OwnNy' <br /> 1-1 Type ❑Residue ❑Partial Rejecfion ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.AhertaN Faclbty(o Generator) US.EPA ID Number <br /> J <br /> U <br /> LL <br /> Fell Phone: <br /> W 18c.SignauredAgemam Faclety(o Generator) Month Day Year <br /> a <br /> z <br /> N19.Haze nt Method Codes(i.e.,codes for hazardous wsm treatment dspasal,and recycling systems) <br /> 1. 2. 3. d. <br /> 20.pesi Fad er ator: of receipt I MzaNaus netsmen a as now in mon j0d <br /> 1 P ay r <br /> EPA Farm 700.22(Rev.3-05) Previous with s are obsolete. - <br /> 10511.1315 L>ESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />