Laserfiche WebLink
0 <br />Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) <br />0 <br />Form Approved. OMB No. 2050-0039 <br />EPA <br />EPA Form 8700-22 (Rev, VS) Previous editions are obsolete. a DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED( <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />WASTE MANIFEST CALOOO194471 <br />1 <br />888-785-7225 <br />Q o 3 15 FLE <br />5. Generator's Name and Mailing Address Generators Site Address (it different than mailing adoress) <br />Central Valley Taste Services Inc <br />1333 E Turner Bd. <br />Lodi, Co. 95240 <br />Generators Phone: 1110 aii-5677 <br />6. Transporter 1 Company Name <br />U.S. EPA ID Number <br />Advanced Chemical Transport <br />CAR000070540 <br />7. Transporter 2 Company Name <br />U.S. EPA ID Number <br />8. Designated Facility Name and Site Address <br />U.S. EPA ID Number <br />IIS Ecology Nevada, Inc. <br />P-0Bon 578, tiny 95, 11 miles S. Beatty <br />Beatty, NV 89003 <br />Facility's Phone: 800-239-3943 <br />NM30010000 <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number. <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing It an <br />9 Grou p ( YII <br />Quantity <br />Wt./Vol. <br />1. Hon RCRA Namardous Waste, Solid (Grease) <br />352j <br />0- <br />z <br />W <br />3. <br />x i <br />4. <br />3 <br />14. Special Handling Instructions and Additional Information <br />1) 070128300-1.385; i-/ CEQ -d0 S �� d � , <br />Project Number: CV02324-02 <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment am fully and accurately descnbed above by the proper shipping name, and are classified, packaged, <br />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 <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I cerfify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) if i am a small quay fity generator) is true, <br />ene risofferars nntetl <br />Name 6ignature <br />month uary Year <br />�i1 <br />. ntemational Shipments <br />El import to U.S. LJ Export from US. Port of entry/exit_. <br />1- <br />Transporter sinature for exports only): Date leaving U.S.: <br />w <br />17. TranspliderAcknowledgmenl of Receipt of Materials <br />F' <br />Transporter 1 Printed7Typed Nam4MC ignaNre <br />on Year <br />a <br />;IS <br />(ay <br />1 <br />QTransporter <br />2 PrintedlTyped Name Si nature <br />aril Day Year <br />H- <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Ouani y ❑ Type ❑ Residue <br />❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />181b. Alternate Facility (or Generator) <br />U.S. EPA tD Number <br />J <br />U <br />LL <br />Facili 's Phone: <br />W <br />liffelgnalureofAttemate Fadlity jo(Generator) <br />Month Day Year <br />Q <br />2 <br />CD <br />W <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment disposal. and recycling systems) <br />W <br />,. <br />2 <br />3. <br />4, <br />0 <br />20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item Ise <br />PrintedlTyped Name lure <br />/(�_ <br />Month Day Year <br />1511 -7111 - <br />EPA <br />EPA Form 8700-22 (Rev, VS) Previous editions are obsolete. a DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED( <br />