Laserfiche WebLink
01/03/2012 13:43 2098631 <br />'i. <br />Please onnlor Mce. (Form destined for use on elite (12-otch) tvoevmter.Y�- <br />RIVERBANK OIL T#SF <br />PAGE 01 <br />Form Approved. OMB No. 20SM039 <br />urn Furor oruu-a tR:,v, uat rrawous emoons are cbe. ieR. DESIGNATED FACILITY TO GENERATOR STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS 11 GBnernorlDNumber <br />2. Paget of <br />3. Emergency Response Phoms <br />14. Hardt Tmking Numor <br />1'3 0 3 0 2 5 2 2 6 FLE <br />WASTE MANIFESTICA4t ., <br />JOW5, <br />t <br />-33�*4�? <br />Genereots Name and Mal Address Gbnomtbr's site resat it deterent Iran mailing address) <br />CC&A*?,arVP-! �2�7 1333 e.,Ta2lGam. <br />17OAOY-;741000 Lova, CA.9f�240 <br />-10C>1)n5t`g5.'2 I X333— <br />rators <br />o Irangporter 1 Comm'pan'+y ac�me U.S. EPA IG Number <br />koipga <br />7. fransWer 2 Company Name U.S. EPA IO Number <br />S. Designated Facility Nam and Sale AOdresa US EPA ID Number <br />��eao c% ->Qs szv CA'T' 000190 816 <br />wRA*jKIcA,- 95' 7 <br />F il`aPh <br />9a. <br />9b. U.S. DOT Description (Includhg Proper Shippmg Name, Hazard Class, l0 Number, <br />10. Contaktea <br />11. Total <br />12. unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and PackMg Group (it any)) <br />Quantity <br />WINd. <br />o <br />�� RcA t�a�aRvcs r�sc� . <br />1 <br />18 <br />t7l21 <br />a <br />w <br />2. <br />3. <br />4 <br />u: Special Handling Instructions and AddhonalInforrmation <br />13 <br />15, GENERATOR'SfDFFMM'SCERTIF'ICATION! I hereby declare that the contents of this oonslgnmeml are fully and accurately deeWbed shmm by the pmperahWhV terms, and are classified. packeged. <br />marked and lebeledfplacerded, and are m a0 respac5 in proper corddan for amnsport acmmmg to applicable Inloma ktru[ and ms9onN gowmmontnl regu4mlgng, If export sHpmmt and I am the Pr its ry <br />Exporter, I msrtity that me comerse of thla consignment conform to the tame of the atac ied EPAAcknmoedgmrern of Caneett. <br />earuy, that the wxla minimlzalion,taN+rx;m ldcnll5cr11n 40 CFR 2B2,7,1(a)fRlamamrgr:ownllry. nca )(ttI erM <br />smalls 9mta)lg true. <br />Gerrtxxor oaelms Prmlednypea Name a — _mumn Day Year <br />0 <br />* <br />International SMpmenb - <br />n u s. ❑Taman to U.S. ❑Eayrxt ham Us. Pon derrhy/exit_ <br />—Tranestnors <br />re fora only), Date leaving U.S.: <br />17, Transporter Adm ModiXnant of Receipt ofMah als <br />d. <br />Imr45ponefl Prmteoliytr.dmma Month Day Veer <br />a <br />N <br />ro <br />Imnsporler2Primennyped Nam ,n"re MmTth Day Year <br />18. DI.ecrepency <br />18a. Drreaepancy lodiarkri Spam C1 Quantity ❑Type ❑Resldure ❑Partial Rgectian ❑RA Rejection <br />Manifest Reference Number. <br />184 Attempts Facility for Gewra o0 U.S. EPA ID Number <br />J <br />U <br />6 <br />Faalrys Phone: <br />let. Signature ofAltemale Facility (x Generator) Month Day Year <br />1a' <br />N19. <br />Haomdous Waste al Managament Method COdes(i.p., mda5 fa/ hexardous weds bmtrenf- d*rose, and reeycimgeyslans) <br />Oh2O <br />2. i. <br />d. <br />ealgl6 FapUty Onmer m Operator Comtumton ofm of hazardous mi rials covered by the mantissa excW as rated In Ilam 1a.1dllyped <br />$klnatum Mnmlr pay <br />Nam• /�J <br />4�� ay� <br />urn Furor oruu-a tR:,v, uat rrawous emoons are cbe. ieR. DESIGNATED FACILITY TO GENERATOR STATE (IF REQUIRED) <br />