COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

CV 6P 1 Please p0161, or type. (Form designed for use on elite (12 -pitch) typevinter.) �— " ' `' Form Approved OMB No 20500039 Ern norm 870o-22 (Rev. sue) Previous editions ares obsolete. 11 DESIGNATED FACILITY OtErTINATION STATE (IF REQUIRED) UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone/. ManNest Tracking Number WASTE MANIFEST M000194471 1 866-333-9222 1003025078 FLE 5, Generators Name and Mailing Address Generator's Site Address (it different than mailing address) Central Valley Taste Services Inc 1333 E Tux r Rd_ PO Don 241001 Lodi, Ca. 95240 Lodi, Ca_ 95241 Generators Phone: 9OG ii9—RAII . Transporterl Company Name U.S. EPA ID Number Advanced Chemical Transport CAR000070540 7. Transporter 2 Company Name U.S. EPA 10 Number 8. Designated Facility Name and Site Address U.S. EPA ID Number Clean Harbors of San Jose, LLC (San Jose Facility) 1021 Derryessa Road Sm Jose, CA 95133 Faality's Phone: 408-441-0962 CAD059494310 go, 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)) Quantity WINd. 13. Waste Codes No. Type 1. IIH1263, Waste Paint, 3, PGII, RQ (D001) D00 D03 34 rr 1 DK 55 G 2. w 3. 4, • ,�. 14, Special Handling Insbucfions and Additional Information/� D') 1) ERG A: 128; CH322832; CEC-qn Ir (]` ERGt128 Project Number: CV00803 15. GENERATOR'SIGFFEROR'S CERTIFICATION: I hereby declare that the contents of this cdnsgnment are fully and aco nitely described above by the shipping name, and proper are classified, packaged, marked and labeled/placed, and am in all respects In proper condition for transport according to applicable international and natiorel governmental regulations. If expect shipment and I am the Primary Exporter, I certify that the contents of this cd signmenl conform to the term of the attached EPA Acknowledgment of Consem. I certify that the waste minimization statement identified in 40 CFR 262.27(x) IN I em a large quantity generator) or (b) (A I am a small quantity generator) Is oge. enerato s Printed/Typed Name`s gna monffi ay ear G Z F 1 .unsimatonal Shipments 1:1 Import to U.S. ❑Export .s. Portotenlry/exit =I Transporter s' nature for exports only): Date leave U.S: w 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintedlTyped Name ay ea aC za Transporter2 P ntedlTyped Na gnature ay ear 18. Discrepancy '- 1B& Discrepancy Indication Space ❑ ouantl N ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number 18b, Alternate Facility (or Generator) U.S. EPA ID Number J U LL 's Faal' Phone: W 18c. Signature of Alternate Facility(or Generator) Month Day Year ZZ Zn— 19. Hazardous Waste Report Management Method Codes (i.e., codes far hazardous waste treatment, disposal, and recycling systems) W 1. / / !/ 2. 3. 4. 20. Designated Facility Owner or Operates Certification of receipt of hazardous materials covered by the manifest except as in Item 19a Pnnt Name Signature i Month Day Year IaA6 V01 Ern norm 870o-22 (Rev. sue) Previous editions ares obsolete. 11 DESIGNATED FACILITY OtErTINATION STATE (IF REQUIRED)