Laserfiche WebLink
i)111 -v NAIL i tK_ <br />WHITE -ORIGINAL (Return to Generator) YELLOW-TSOF (Retain Copy) PINK -TRANSPORTER COPY GOLDENROD -GENERATOR'S COPY <br />NON -HAZARDOUS 1. Generator's US EPA Ib No, <br />2, Page 1 <br />3, Document Number <br />WASTE MANIFEST <br />AL <br />4. Generator'a Name and Malting Addrom <br />UniffPcil Grt�cers <br />1990 Piccoli Road <br />STOCktort, CA 95715 <br />Generator's Phone <br />5. Transporter Company Name 6_ US EPA ID Number <br />7. Transporter Phone <br />Icon Environmental 5enrfte5 CAL 000 362 960 <br />CL"EARW ElWt1ROWE MIL <br />(510) 476-_174_0 <br />8. Dasigneled Facility Name and site Address 9. US EPA ID Number <br />10. Facility's Phone <br />Icon Environmental 5ervices Inc <br />510-476-1740 <br />1.270 Whipple Road CAL 000 369 026 <br />Union City, CA 94587 <br />E <br />N <br />11, Waste Shfpping Name and Description <br />12- Containers 13. 14. <br />F <br />_.r . <br />Unit <br />—......".-No. Quanf WWoI <br />R <br />A <br />T <br />a. <br />Non -Hazardous waste <br />—�T_Y <br />0 <br />R <br />. _.._...._. <br />b. <br />15. Special Handfing Instructlons and Additional Information <br />Handling Codes for WaStas Listed Above <br />Wear PPE <br />118. 11a. <br />Emergency Contact <br />(510) 476-1740 <br />Attn: Charles Seaton <br />SEPI 9 2014 <br />Clean Tech Environmental <br />ENVIRONMENTAL HEALTH <br />DEPARTMENT <br />16. dENERATOW9 CERTIFICATION- I certify the malarials described above on this manifest are not SobjeCt 1e st210 or federal reou]00S for reporting proper disposal or Hazardous Waste. <br />T <br />Print&V yped Name <br />Signature <br />R <br />A <br />Month Day Year <br />S <br />p <br />17. Transporter Acknowledgement of laecetpt of Materials <br />O <br />R <br />PrintedRyppd Name <br />Signature <br />T <br />- <br />r <br />Month 0 `Yoor <br />18.Olacrapancy tnellcatlon spaca <br />F <br />A <br />C <br />I <br />L <br />I <br />T <br />Y <br />19. Facility Owner or Operator: Certification of recelpt of waste materiels covered by Chia manifest except as noted in Item 1a. <br />Printedrryped Name <br />Signature <br />Month Day Year <br />WHITE -ORIGINAL (Return to Generator) YELLOW-TSOF (Retain Copy) PINK -TRANSPORTER COPY GOLDENROD -GENERATOR'S COPY <br />