Laserfiche WebLink
Fi. « c:/ t7.0.Box 400 Sacramento,C&�;�12-) tih1n 30 days.*' <br /> Please print or type.(Form designed for use on elite(12•pilch pewdter.) E ES4 . Form Approved.OMB No.205D-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID umber �g 2.Page I of 3.Emergency Response Phone 4.Manifest Tracking Number �/ <br /> WASTE MANIFEST C-.,.'A to 000 -1144 OU"Y 1 1-8400 24-03M 010023991 JJK <br /> k mfor'eaa dMeiliAdd`� ��,� _-4, 8G-4[ R, Generator's Site Address(if different than mailing address) <br /> �>r'j.. <br /> RECD JUL 212 015 <br /> Generators Phone. <✓� <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> f-VEP13n", E 4 t"„vVf'iiCitiA, [,U4TAt. fti"I4l3CEIS CAD9824'13262 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address tr4'Fi'1QWCN Ci3,,. INC. U.S.EPA ID Number <br /> 0030 WM H AVENUE <br /> NEWARK CA 94500 CAD980887418 <br /> Facility's Phone: 810-79fG-4400 <br /> 90. 9b.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 Quantity Aft./Vol. <br /> 1' NON-R, 'IA HAZARDOUS WASTE. LIQUID 001 TT G <br /> z 2. <br /> W <br /> 3. <br /> 4. <br /> 14 Special Hendlin ins Wctlonsand AddlBonelnkmiahon <br /> INVOICE <br /> DOT F806 171 WSAR PROTI,CTIVE CLOTHING � SALES ORDER# <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment am fully and accurately described above by the proper shipping now,and are classified,packaged, <br /> marked and Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable International and national governmental regulagons.If export shipment and I am Ne Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement Identified In 40 GFR 262.27(a)if I am a large quantity generator or(b)(91 am a small quantity generator)Is We. <br /> r- Month Da Year <br /> GeDprelo�Offerors PnntedR ed Name (Signatyfe� � �, 1��••--••""' t � Y t <br /> �irV '" <br /> 16.International Shipments ! - <br /> p_ ❑Impo to U.S. ❑Export tp5m U.S. Pon of entryle It: <br /> Z Transporter signature(for expods only): Date leaving U.S.: <br /> 17.TranspoderAcknowledgment of Receipto rials <br /> CTransporter l P„pnledRy7d Name. .t*"w.., Signature .o �.^'�'- "'"'""'•' Month Day Year <br /> i k t '`S,.... r ,. .. <br /> 4 Transporter 2 Pdntedlryped Name Signature v Month Day Year <br /> K <br /> r z <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑PaNaI Rejection ❑Fug Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> rat Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and iegcling systems) <br /> Q 1 <br /> 20.Designated Facility Owner or Operator:Certification of moelpt of hazardous materials covered by the manifest except as noted In Item 180 <br /> PrinteOMd Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3.05) Previous edl8ons are obsolete. GENERATOR'S INITIAL COPY <br />