Laserfiche WebLink
• • <br /> Please r� <br /> or type.(Form designed for use on eW(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator®!Naber 2.Page 1 of 3.Emergency Response Phone4.MaY�nTracking Number <br /> ��Hesf <br /> WASTE MANIFEST U 0 370558 SKS <br /> 5,Generator's Name and Me Generators Site Acdress(if different than mailing address) <br /> . RIE;; <br /> CA 95;130 <br /> Generators Phone: `1 <br /> 6.Transporter 1.Company tlame y V_,T&}+S T U.S.EPA ID Number <br /> i <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address 9(�{�F T`r-•;:I..FI--iV aY;�TEMS INC.. ;''•f;. i + U.S.EPA ID Number <br /> 1722 COOPER CREEK EfRID <br /> QF-NTON TX <br /> TXD077603371 <br /> Facilitys Phone: <br /> 9a, 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)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> WON RC144 HW/. R1sUU i <br /> o !i7tKORLENT AND OIL) <br /> z 2. <br /> W <br /> - 1 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information SK T K.:K It 1 I I c:4p- 444 ` <br /> HR EMERGENCY 800 469-17E0(SAFET'w--KLEEN - 4139) <br /> 1)I <br /> I'll 4 Y1� ( q�- rt Crt'!T7 Cl''?T r r:. <br /> ri 7 �- �.("1'i- �, 1": ) !?, <br /> 15. GENERATOR'SfOFFEROR'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 labeledlplacarded,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 EPAAcknowledgmenl of Consent <br /> I certify that the waste minimization statement Identified in 40 CFR 262.27(a)(d I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generatoes/Offeroes Printed/Typed Name Signature Month Day Year <br /> -J 16.International Shipments <br /> F_ ❑Import to U.S. ❑Export from U.S. Port of entry/exit <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Matenals <br /> Transporter t PrintedfTyped Name Signature Month Day Year <br /> O <br /> a <br /> COP) <br /> Transporter Pdnted/Typed Name Signature Month Day Year <br /> Of <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication SpaceEll <br /> ❑ Quantity ❑Type ❑Residue E]Partial Rejection Full Rejection <br /> Mandest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> Facility's Phone: <br /> LU 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> y z <br /> i y 19.Hazardous`haste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> C 1. 2. 3. 4. I <br /> I <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> €PA Form 8700-22(Rev.3-05) Previous editionsare obsolete. GENERATOR'S INITIAL COPY <br /> 0ltl. i <br />