Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch)lypewrlter) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of Erpa�gencyR�5ponsgp�pn� 4.Manifest Tracking Number <br /> rARQy+I010c.'7U'7 —Wlln-y-t tt- 7 /LY /� <br /> WASTE MANIFEST l f i 3 SKS <br /> 5.Generation's Name and Mailing Address Generator's Site Address(N different than mailing address) <br /> HOLZ RUBBER COMPANY INC. <br /> 1129 S Sscraraent0 St <br /> Lodi CA 95240--5701 <br /> Generator's Phone: E1PEI-'285 1600 <br /> ji� l}'MTVGYFTE,MS, INC. U.S.EPA ID Number TXR000050930 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address US ECOLOGY NEVADA 1AS-fy4lDNumber <br /> 11 MILES 5 OF RFATTY HWY 95 <br /> BEATTY , NU 6900;3 <br /> NU'i33N01 ka <br /> 800--2:39--±943 trj30 <br /> Facilitys Phone. <br /> ga 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13,Waste Codes <br /> HM and Packing Group(if any)) No. - Type Ouanfity Wt./i <br /> 1 NON Rr RA HWARDOUS WAri CF' L I QU I Wi OM F 223 <br /> !ABSORBENT AND Olt. ) S <br /> z 2. <br /> W <br /> f) <br /> 3. <br /> 4, <br /> 14,Special Handling Instructions and Additional information R1( $HIP#2068030.82 57501408 3153217 CSG: <br /> 24 HR EAERGENCY 1111-800-468--1760 (SAFETY—KLEEN — CONTRACT #94138) <br /> SK r rp"_71 9 <br /> 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 n ssified,packaged, <br /> marked and labeled/placarded,and are In all respects in proper condition for transport according to applicable international and national govemmental regulations.If export shipment and i am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the tens of the attached EPA Acknowledgment of Consent. <br /> I cortify that the waste minimization statement Identified In 40 CFR 262.27(x)(if I am a large quantity generator)or(b)IN am a small quantity generator)is true. <br /> Generator's/Offeror's PdntedlTyped Name Signature Month Day Year <br /> f� <br /> 16.International ShipmentsExportF <br /> El Import to U.S. ❑Ezport from U.S. Port of entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> 17,Transporter Acknowledgment of Receipt of Materials <br /> K Transypder 1 Pdntedlfyped Name Signature Month Day Year <br /> oa <br /> QTraftililporter2 PrintsairryltedName igni Month gay Year <br /> K <br /> r— <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residue ❑PaNa1 Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA to Number <br /> J <br /> U <br /> ra+. Faciliys Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) on Day Year <br /> Q <br /> z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the mandest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22((Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> 1)4002601 i 2,305 <br />