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 HAZARf]pUS 1.Generator ID Number 2.Page t of 3.Emergency Response Phone 4.Manifest Tracking Number r 1 WASTE MANIFEST -- JJK- 5.5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) 1010 W,Va.00O Roac 'A 95.376 Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number F INVIRCG L.. iiVG 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number 35251 OLD SKYLING BLVD CATODOPAS117 KETTLEMANCITY, CA Facil'ty's Phone: r te`r"' ga, gb.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.rVol, t t-iamrdous waste Corrosive,Acidic.IrKw90 o PG111 W 4. Z 2. W c� 3, E 14.Special Handling 4nstructions and Additional Information JE j F'(Offle 4P�-;A1z;J43d t UE iia#jci3 l WEAR PROPER P P E WHEN HANDJING 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, marked and labeled/placarded,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,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowiedgment of Consent, I certify that the waste minimization statement identified in 40 CFR 262.27(x)(if I am a large quantity generator)or(b)(if l am a sinal[quantity generator)is true. GeneralerslOfferors Printedrryped Name Signature Month Day Year J 16,int mational Shipments z ❑Import to U.& ❑Export from U.S. Port of entry'/exit: Transporter signature(for exports only): Date leaving U.S.: U 17.Transporter Acknowledgment of Receipt of Materials Tran Mer 1 Printtedrryped Name f Signature I— Month Day Year O ' fJ y ZZ Transporter 2 Printed/Typed Name Signature' Month Day Year H 18.Discrepancy 18a.Discrepancy Indidation Space ' ❑ Quantity 1:2 Type L:1 Residue ❑Partial Rejection Full Rejection I l Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ V LL Facility's Phone: W 18c.Signature of Aiternate Facility(or Generator) Month Day Year d Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 2. 3. 4, 1 I 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as poled in Item 18a Prnted7ypedName Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR