Laserfiche WebLink
U Folfin Approved.OMB No.2050-0039 <br /> Pkie pont or type.(Form designed for use on elle(12-pitch)typewriter.) <br /> 2.Page 1 of 3.Emergency Response Phone 4.Manifest Trac <br /> 1.Generator ID Number king Number <br /> UNIFORM HAZARDOUS ) 916-649—014 <br /> WASTE MANIFEST <br /> 5,Generators Name and Mailing Address <br /> Generelors Site Atldress('d different than mailing address) <br /> Generators Phone: U.S.EPA ID Number <br /> 6.Transposer 1 Company Name CAL 913 5a4 912 <br /> U.S.EPA ID Number <br /> 7.Transposer 2 Company Name <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> 110:» `n: lir: '➢ k , ei Aii, RANCHO ;",ORWVA, 'A 9:7'42 ;Ail 3u ik3G 13:5 <br /> FaGli s Phone: g 1 o--4,51-1 980 <br /> 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> ge go.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, N0. Type Quantity WING. <br /> HM and Reciting Group(d any)) <br /> o Ni}R-PLRA iiALt°tk00jc WASTE SOLIDS <br /> W <br /> y <br /> 3. <br /> 4. <br /> 14.Special Handling Instruo8ons and Additional Information <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION: hereby declare that Ne contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeled1placarded,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 /> Exposer,I testy that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I caNy that the waste minimization statement identified in 40 CFR 262.27(a)(d 1 am a large quantity generator)or(b)(if I am a small quantity generator)Is true. Month Day Year <br /> Generelofci0iferoi's PrintedRyped Name <br /> Signature <br /> FJ- 16,International Shipments ❑Import b U.S. ❑Export from U.S. Port of entrylaft: <br /> Z Date leaving U.S.: <br /> Transposer signature(for experts only): <br /> W 17.Transporter Aclalowledgment of Rei of Materials Montle Oay Year <br /> W Signature <br /> Transporter 1 Prinied(Typed Name <br /> 2 Transposer 2Prind sell Name Signature m e ' e Month Day Year <br /> rn <br /> Q <br /> C <br /> r <br /> t18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑ Pal❑PaRejection ❑Full Rejection <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> 18b.Altemate Facility(or Generator) <br /> � J <br /> LL FaGiitys Phone: Month Day year <br /> 18c.Signature of (or Generator) <br /> W <br /> i <br /> 19.Hazardous Waste Repos Management McNod Codes(i.e.,codes for hazardous waste Vestment,disposal,and recyGing systems)3. 4 <br /> 2 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18agyl p�, Year <br /> Signature <br /> Printe,irryped Name <br /> EPA Forts 8700-2.2(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />