Laserfiche WebLink
n IC....n A crit uro nn nliln 112- itch! <br />D'C.33596. 2254 <br />Fan Approved. OMB No. 2850-0039 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />10321.0770 Z. <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page I of <br />3. Emergency Response Phone <br />4. Manifest Tracking Number <br />1 003884926 <br />JJ K <br />WASTE MANIFEST CAI=19d471 <br />1 <br />8300.321.1030 <br />5. Generators Name and Mailing Address Generators Site Address (if different than mailing address) +; <br />Central Valley Waste Service <br />133 East Turner Road <br />Lodi, CA 95240 <br />Generators Phone: 29-369-3274 <br />6. Transporter l Company N:n I <br />/lam <br />U.S. EPAID Number <br />G 000 1 <br />T. Transporter 2 Company Name <br />U.S. EPA 10 Number <br />5�(e <br />B. D cliBrn9C�l W �ridll3 <br />U.S. EPA ID NumberA <br />CT000646117 <br />35251 Old SRyllne Road <br />Kettleman City, CA 93239 <br />Facifys Phone: 559-366'9711 <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containersif. <br />Total <br />12. Unit <br />13, <br />Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group r any)) <br />Quantity <br />W1NOI. <br />1 Non•RCRA Hazardous Waste, Solid (6011 4111111 lead) <br />1 <br />DT <br />18 <br />Y <br />611 <br />z <br />0 <br />z <br />z. <br />w <br />07 <br />3. <br />lylipecial Handling inshcbons and Additional Information - <br />Wear Proper Clotning When Handling Materia <br />ERG X. WA <br />Profile # CA236562 (Son Oil IEauu) <br />15 GENERATOR'SIOFFEROR'S CERTIFICATION: I hereb adore that the contents of this consignment are fully and accurately described above <br />by me proper shipping name, and are classified, packaged, <br />marked and labeled/placarded, and are in all respects proper condition for transport according to applicable intemationaland national governmental regulations. It export shipment ands <br />am the Primary <br />Exporter, I cortiry that me wntenis of Nis ensign t conform to the terms of the attached EPA Acknowledgment of Consent. <br />'fy that me waste minimization slateme entified in 40 CFR 262.27(a) fit l am a large quantity generator) or (b) (if I am a small quantity generatic) H he. <br />GeneOffem s PnntedlTyped Nam Signature <br />Month Day Year <br />/ <br />d <br />O <br />p_❑ <br />16. International Shipments <br />Import to U.S. ❑ Expmi brim U.S. Port of enbylaxit: <br />Transporter signature (far exports only): Date leaving US.: <br />w <br />17. TransporterAcknowledgment of Receipt of Materials <br />rob <br />Transporter 1 PhTyped arae Signature(n r� <br />Month )Day Year <br />yI <br />Transporter 2 ame Signature <br />month Day Year <br />Ic <br />abt- <br />♦ <br />18. Discrepancy <br />laa. Discrepancy Indication Space ❑ Quantiry EJ Type ❑ Residue <br />❑ Partial Repan <br />❑ Full Rejection <br />Manifest Reference Number <br />i8b. ARemale Facility (or Geneator) <br />U.S. EPA ID Number <br />J_ <br />V <br />rat <br />w <br />Fabliys Phone: <br />18c. Signature otAltemate Facility (or Generator) <br />MonthOay Year <br />Q <br />2 <br />N19. <br />Hazardous este Report Management Method Codes (i.e., codes kr hazardous waste treatment, disposal, and recyding systems) <br />2. 3. <br />4. <br />Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 183 <br />I20. <br />PrintedRyped N e ^ Signature <br />6,5 R11 <br />EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />10321.0770 Z. <br />