Laserfiche WebLink
Please Print or h IIIIII IIII IIIII�III�'III II�III II�IIII� <br /> p type.(Form designed for use on elite(72-pitch)typewriter.) Form Approved,OMB No.2050-0039 <br /> UfJIFORM HAZARDOUS 1,Generales ID Number 2.Page 1 of 3.Emergency Response Phone 4,Manifest Tracking Number <br /> WASTE MANIFEST CAD 9 8 2 4 1 6 0 1 0 , 77 1 0 0 0 5 4 405' 6 5 VES <br /> 5.Generator's Name and Matting Address pS� p�oI (- Generators Site Address(if different than mailing address) <br /> YQ95 Qr1 '- LANE SAME <br /> STOCKTON.CA 90206 <br /> Generators Phone:209 483-6014 <br /> 6,Transporter 1 Company Name U.S.EPA ID Number <br /> VEOUA ES TECHNICAL SOLUTIONS IN J D 0 8 0 6 3 1 3 6 9 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site AddressVEOLIAES TECHNICAL SOLUTIONS. U.S.EPA ID Number <br /> L.L.C. <br /> 1125 HENSLEY STREET <br /> FacilitysPhone: 800 24:23$2 RICHMOND,CA 94801 C A T 0 8 0 0 1 4 0 7 0 <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.T01al 12.Unit <br /> HM and Packing Group(f any)) 18.Waste Codes <br /> No. Type Quantity WINd. <br /> X 'UN 1719,WASTE CAUSTIC ALKALI LIQUIDS,nos., D002 <br /> o ((POTASSIUM HYDROXIDE,ETHOXYLATED NONYLPHENOL), _ <br /> pia 8,11,RQ(D002) 0 0 1 D F 0 0 2 4 0 P 122 <br /> w <br /> Z 2. <br /> w <br /> � I <br /> 3. <br /> 4, <br /> I <br /> 14.Special Hantllinc lnsWctions antl Additional Information ER Service Contracted by VESTS + 1)ERG:154 W.763804 A:RMD-INC <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by are proper shipping name.and are classified,packaged, <br /> marked and Iabeledicacarded,and are N all respects in proper condition for transport according to applicable international and nations(governmental regulations.If export shipment and I am the Primary <br /> Exporter,I ceddy that the contents of this consignment conform to the terms of the attached EPAAcknoWedgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)lir(b)(itI am a small quantity generator)is We. <br /> Generalorsl0fferors Pnnled/Typed Name Signature _ Month Day Year <br /> 0 9 10 7 11 1 <br /> 16.Intema6onalhipments <br /> Z 11Importto U.S. El Dwrt from U.S. Pon of entrylexR <br /> Transporter signature(for exports only) Date leaving U.S.: <br /> w 17.TransporterAcknoMedgment of Receipt of Materials <br /> Transporter l Prined7fyped Name Signature Month Day Year <br /> N JONATHAN P.GORDON 10 9 10 ? 11 1 <br /> Q Transporter 2 Printedryped Name Signa Month Day Year <br /> rY <br /> r <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space 0 Quantity ❑Type ❑Residue 0 Partial Rejedion 0 Full Rejection <br /> r 181b.Alternate Fadldy(or Gcroemtor) Manifest Reference Number. US.EPA ID Number <br /> J <br /> U <br /> LL Facilitys Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> f0 <br /> 19.Hazardous Waste Report Management Method Codes a e.,codes for hazardous waste averment,disposal,and recycling systems) <br /> N <br /> 1 2. 3. 4. <br /> 20.Designated Facility Owner or Operator.Cedi cation of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> 1f Name Month <br /> alure MonthDay Year <br /> Vl <br /> EPA Form 8700-22(Rev,3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />