COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

Please print or type.(Form designed for use on elite(12-pitch)typewriter.) 7Q192 Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST 1 CARO$0247213 2 86695/9824 008553873 F L E 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Safeway NorCal #1769 Safeway NorCal#1769 2094615555 2808 Country Club 2808 Country Club Generator's Phone: Stockton, CA 95204 Stockton CA 95204 6.Transporter 1 Company Name U.S.EPA ID Number Stericycle Specialty Waste Solutions Inc MNS000110924 7.Transporter 2 Company Name U.S.EPA ID Number s � ��G3z13 3 8.Designated Facility Name and Site Address General Environmental Mgt, LLC U.S.EPA ID Number 11855 White Rock Road Rancho Cordova, CA 95742 i� Facility's Phone:9163510980 Al 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. X 11JN3077, Waste Environmentally hazardous i CF 00006 P141 D009 0 substances, solid, n. o. s. (Mercury), 99 PG III. FREA1171 WLU X 2JN3266, Waste Corrosive liquid, basic, 1 CF 00035 P 122-D002 , ,, inorganic, n. o. s. (Potassium Hydroxide, Sodium Hypochlorite), .8 PG II ERG#154 X 3.1N1950, Waste Aerosols, [flammable, (each not 1 CF 00003 A 214 D001 exceeding i L capacity)-3 2.1, ERG#126- X 4JN19931 Waste Flammable liquids, n.o.s. 1 HA 00001 P 214 D001 D035 v (Acetone, Alcohols), 3, PG II, ERG#128 14.Special Handling Instructions and Additional Information 1. 102583(Hroken Fluorescent Bulbs) - 2.-4692(Hasic Liquids, Corrosive) 3.4690(Aerosol) 4.PKG-DFe4691 (Flammable Liquids) + 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are full and accur ely d ribe abo by the pro shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable ternational an nat nal ve ental regul ons.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 Acknow d ent of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantitygen a r)or(b)(if I am I qu nt erator)is e. enerator's/Offeror's Printed/Typed Name igna!Z__ jaj on ay Year r/- (YDC7 07 16.International Shipments H ❑Import to U.S. ❑Export from U.S. PorTof entry/exit: Z Transporter signature for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Ll Transporter 1 Printed/Typed Name Month Day Year a Isidro Martinez 1 07 : 28120 M Transporter 2 Printed/Typed Name Month Day Year f- 18.Discrepancy J 18a.Discrepancy Indication Space ❑ Ouantity ❑Type ❑Residuej j ❑Partial Rejection El Rejection Manifest Reference Number: 18b,Alternate Facility(or Generator) �5 t �n �`cowv2'� f � nt � U.S.EPA ID Number a F fvSc�.y�c� ;2-001K�60i tia S VY, ta-S t T�a(VIR� INV LL Facility's Phone: C> w W 18c.Signature of Alternate Facility or Generator Month Day Year Q z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste +sposa,and recycling systems) 0 L ' 2. � 3. � 4. I C 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 183 Printed/Typed Name ( ( Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. ED- 8700-2212v3 s;'8700-22122v3 CAL20080023 840002718 041896684 M PD072817 SD072817