Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch)typewriter) _:_- Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2 Page i of 3 Emergency Response Phone 4.M rfe T cking Number <br /> 'WASTE MANIFEST C A 7,:10 0 A 6'i 5 6 1. (8(Xl)424-9, , T 0 5 3 312 JJ K <br /> 5.Generators Name and Mailing Address Generators Site Address(it different than mailing address) <br /> E:_ H:FINING LLC-ECS001 <br /> 22221 S SINCLAIR AVE <br /> STUCKT;"rr! ra 95'15 <br /> Generators Phone: ::091745l70L' <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> ;**13i)i' *1ENTALSERVICE'S C A D 0' tC 7 0 3 e <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address - U.S.EPA ID Number <br /> DENIIENNC)/KLRDUON <br /> 2?00 N.AlAWDA STREF1 <br /> COM"rTOF, CA 90222 C A.'T'0 3 0 0 13 3 5 <br /> Facililys Phone: �,t;�,�,-q� .,7-;.�-r; <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Container: 11.Total 12.Unit <br /> HM and Packing Group(if any)) o. 13.Waste Codes <br /> NType Quantity WtIVol. <br /> 1' ^i:ltd RC RP. ,-ivARoous WASTE. LIQUID(ETHYLENE GLYCOL L l <br /> S-0t.U1'10W V' :� - 133 1 <br /> i <br /> I <br /> 2' I HIS WASTE STREAM HAS BEEN QUALIFIED <br /> FOR RECYCLING/TREATMENTS AT THE -- " <br /> 3. DeMENNO 1 KERDOON FACINTY I;! COMPMN, I <br /> CALIFORNIA.THIS FACILITY HAS THE NECESSARY !PERmrs <br /> R f' l mug' + T snuus V' <br /> 4. QUALPED.MR EPA NUMBER IS CATOBC4313352 <br /> 14.Special Handling Instructions andAdditiond Information <br /> C; c :.-6UV-424-9300 NAERW 98121 171 *PROFILES 9B1 383643 ETHYLENE G!YCUL <br /> APP I?UPRIAf.'PFRSGNAI.PROTECTIVE EQUIPMENT <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 are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper candition for transport according to applicable intemational and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I teddy that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I cedty,that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantify generator)or(b)tiff a'small quantity generator)is true. <br /> Generators/ORerors Pnntedrryped Name Signature '" Month Day Year <br /> J 16.International Shipments <br /> ❑ <br /> Z Import to U.S. ❑Export from U.S.^ Part ofentry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: - <br /> W17.Transporter Acknowledgment of Receipt of Materials <br /> O Transporter l Printed/Typed Name Signature i Month Day Year <br /> N <br /> Z Transporter 2 Prinledlryped Name Signature <br /> Q 9 Monts Day Year <br /> K <br /> F- <br /> .H iB.Discrepanry, <br /> 18a.Disaepancy Indication Space ❑ Quantity ❑Type ❑Residue �"'�)iy"1O - Pya�-rtiel 'ecy¢enr:.,, ElFull Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) , . U.S.EPA ID Number <br /> J q <br /> LL Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) { Month Day Year <br /> a PERMTT/SERISICES <br /> z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recyding systems) <br /> 2. 3. 4. <br /> 20.Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrinedT ed Name <br /> f 1I .. - ...j Signature ._---ya _-. Monty Day Year <br /> F 3 a?� ! ,./'4 - ,r% ; r;✓� x-.17 xe � /' <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. - - DESIGNATED FACILITY TO GENERATOR <br />