COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

Please print or type.(Form designed for use on elite(12-pitch)typewriter) Form Approved,OMB No,2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number _ WASTE MANIFEST AT000610945' i — 10 2/� 2 5 5 0 7 SKS' 'lJ �f �,i a1 5.Generator's Name and Mailing Address Generator's Site Address(ffdifferent than marling address) .(CMRI.` i-- 400 W VALF'iLO RU TRACY CA 9S376-9197 Generator's Phone: >' "•-1336'-1971 6.Transporter 1 Company Name U.S.EPA ID Number ISLEEN SYSTEMS, INC. TXR000050930 7.Transporter 2 Company Name U.S.EPA iD Number r 8.Designated Facility Name and Site Address SAFETY—KLEEN SYSTE"S, INC ��' � x U.S.EPA ID Number 6000 BOTH STREET SACRAMENTO CA 95828 Facility's Phone: ?16-386--491 C(40000094SI. ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)} 13,Waste Codes No. Type Quantity Wt.fUol. Cr 1'SON—ftL'RA IIAZAl'e'DOUS WASTE, LIQUID (AMIE'CUS PARTS WASHER SOLUTION) i z z. W C9 3. 4. 14.Special Handling Instructions and AdditlonalInformation 'K SFIIP1111200286374 50314284 370202 201014 CSI3: 25 i 15. GENERATOR'S!©FFEROR'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, marked and labeledlplacarded,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 Exporter,l certify,thgtthe contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the sic minimization st mentdenlfied in4. CFR 262.27(a)(if I am a large quantkry generator)or(b)(if i am a small quantity generator)is true. GeneratoeslOfferor' rintadfTyped Nrn Signature Month Day Year -1 16.1 temational hip U- F-- Imps to U.S. ❑Expert from U.S. Port of entry/exit: Z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials t Tra rtes 1 Printed(Typed Name v„� Signature Month Day Year C20L Z Transporter2 PrifitedTIMiff Name orth My 01- 18.Discrepancy �. 18a.Discrepancy Indication Space ❑T ❑ ❑ ❑Fuld Re„tion ❑ Quantity Type Residue Partial Rejection j Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number r U Facility's Phone: W 1 Be Signature of Altemate Facility(or Generator) Month Day Year Q Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,6spesaC,and recycling systems) 2. 3. 4. 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as lied in Item 18a Pytnte9ped Name ----- Signature Month Day Year 4 � EPA Fdrm,8700-22(Rev.3-05) Previous ediftVbrd obsolete. DESIGNATED FACILITY TO GENERATOR