Laserfiche WebLink
Please print or type. (Fane designed for use on elite (12 -pitch) typewriter.) <br />Form Approved. OMB No. 2050-0039 <br />A Form 87M22 (Rev. M5) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />CALF <br />2. Page 1 of <br />3. Emergency Response Phone <br />V; <br />4, ManHeal Tracking Number <br />017145319 <br />WASTE MANIFEST <br />t00,3��XZ _ <br />f <br />16-V I 47 <br />JJ K <br />5. Generator s Name and Mailing Address Genefalprs Site gddre�s Qf QR mvt than mailing address) <br />-J. <br />t3tiF11"1Eti ... - ... , . �� • :r • ,! 1 J`<l �[ f �. . <br />yTOCVTON, CA 954 $4 <br />Generator's Phon6W 4370-9-W7 <br />8. Transporter 1 Comparry Name U.S. EPA ID Number <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />b'. t�iI,.IA L'S T$�ttt. �+GLf.fTk3a#ii <br />:;�:lTAJ.�Jf.ii�7': <br />f tl'6 MEN�ti'Y STPrftl <br />FitW,K*V, CA -3401 <br />FacUl s Phone: <br />ga <br />9b. U.S. DDT Description (including Proper Shipping Name, Hazzard Class, ID Number, <br />10. Contains s <br />f1. Total <br />12. Unit <br />13 Wants Codes <br />No. <br />Type <br />HM <br />and Padding Group (d any)) <br />Quantity <br />WtNal. <br />C <br />SOW, A.t�S, 9, RM (C"H4.1RIA f4d, LEA -01 <br />3 � �•3 <br />Z <br />2.M71 ff { 1-M1,07MIte, <br />OFAfrvoftsEffn <br />CS <br />IF <br />s <br />. <br />t <br />4. Special HandAng Instructions and Additional information sy <br />�l3PR�9FR.�9S �Ig71 9�3}�'f�ih°tt.�13 X71 � �' f i <br />T3.i?. CCrPtFti Ai.IT t R.+lubes {51W 1T�l <br />1,.iyd <br />16. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, arid. are classified, packager!, <br />marked and labeledfplacarded, and are In ant respects In proper condition for transport according to applicable intema0aiel and national governmental regulations. H export shipment and I am the Primary <br />exporter, t certify that the contents of this consignment conform to the.temra of the attached EPA Acknowledgment of Consent <br />I ca" that the waste mlrJmizabon statement Identified In 40 CFR 282.27(a) (If l am a large quentlly generator) or (b) jiff am a small quanitiygeneretor) Is true.. <br />GenerepeV08aroes; PdntedfTyped Nam Signatur@ blop Year, <br />.- <br />T - <br />tx. alorriapor>al Shipments ❑ Import to U.S. ❑ Exom from U.S Pba of ."by/exit <br />Transporter signature (for exports only): Date leaving U.S.: <br />LW <br />17. TransporterAdaxWedgment of Raceiptof Materials ; . <br />rensportertP ntedffyppd�lertre { SI9nA re ,� D Y r <br />w <br />K75 <br />10 <br />rn <br />Transporter 2 PdnWyped Name 81 nature yaw.f.: <br />18. Discrepancy��rr <br />IBa. Discrepancy Indication Space ❑ Quantky ❑Typo LJ Read L1Pertlal Re)ectlon L_I FW.ReJr�loti -: . <br />-a <br />Manifest Reference Number. <br />18b. Alternate Fact* (or Generator) U,S. FBA ID Number <br />t� <br />ua. <br />FaclMys Phone: <br />W� <br />18c. Signature of Alternate Facility (or Generator) <br />19 -Hazardous Waste Report Management Method Codes (Le., codes for hazardous waste treatment, disposal, and recycling systema) <br />1'. <br />2. <br />3. <br />4. <br />20. Designated Facility Owner or Operator. Certification of moelpt of hazardous materials covered by the manifest except as noted In Item I as <br />dnWyped Name Signature Month Day Year <br />A Form 87M22 (Rev. M5) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />