COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

Please print or type. (Form designed for use on,elite (12 -pitch) typewriter.) 1. Generator ID Number 2. F'age 1 of 3. Emergency Response Phone UNIFORM HAZARD001'I WASTE MANIFEST IC A D 9 S 2 5 0 8 2 5 9 5. Generators Name and Mailing Address Generator's Site Address (if different than UNTIed Grocers ltrtif ei1 Grocers Attn: Rat GUWm>ety, :5200 Sheila Street 1990 P4ceol lid. CoMMrCe CA 90040 StoddW CA 951215 Generator's Phone: 7 '? 3 2 F ' - -5 6. Transporter 1 Company Name H;AZ Mat Trans, ;nc. 7. Transporter 2 Company Name Form Approved. OMB No. 2050-0039 ng Number ;95 JJK7 U.S. EPA ID Number C A T 0 8 0 0 1 2 8 0 0 B. Designated Facility Name and Site Address U.S. EPA ID Number Slet' wns Water Tedr ologlas Corp. 5375 Sr5u111 ayle Ave. vemon CA 90058 IC A D 0 9 7 0 3 0 9 9 3 Facility's Phone: 7", 7 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. 'NW RCRA, Hazarekus Wa`a5te Sold 352-- ({)1'r r�'3(iSr81If}�! P ` 14. Special Handling Instructions and Additional Information �Nv�IRC7NME(VTAL �FEAL� 9b.1) of I Absorbent: nrofile4 P165407 DEPARTMENT G10VES & G0991es 15. GENERATOR'SIOFFEROR'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, 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. Generatoes/Offeror's Printed/Typed Name / SignatureMonth {Day Year L Qn I ,r .. ri 16. International Shipments ❑Export from U.S. Port of entrylexit F— ❑ Import to U.S. z Transporter signature (for exports only): Date leaving U.S.: 17. Transporter Acknowledgment of Receipt of Materials w Month Day Year Transporter 1 Printed/Typpe Name / Signature CL F- 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: ,:",. F 18b. Alternate Facility (or Generator) U.S. EPA ID Number M U u Facility's Phone: Month Day Year w 18c. Signature of Alternate Facility (or Generator) Q Z y19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) UJ 3. In 1. 4. it 20. Designated Facility Owner or Operator: Certification of receipt of hazardous piterials covered by the manifest except as noted in Ito 1 0 y' PrintedlTyped Name Signature �! Month Day Year / > "r .� pyo :,• ... OR COA C,...., 1270[1-90 rRav 'Ur,) Previnum editinn.q are obsolete. . -F- ,IMATED FACILITY TO GENERAT