Laserfiche WebLink
• <br />Pleasednt or type (Form designed for use on elite (12 -pitch) typewriter.) <br />fS[- 00!395. 2253 <br />0-0 <br />Farm Approved. OMB No. 205039 <br />EMFomr&700-22(Rw.. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION SIAIC pr nwUiRED) <br />10321.0769 <br />v <br />UNIFORM HAZARDOUS I. Generator ID Number <br />2. Page 1 of <br />7. Emergency Response Phone <br />4. Manifest Tracking Number <br />0038849 <br />JJ K <br />WASTE MANIFEST CAL00019d471 <br />1 <br />300 -321-1030 <br />5. Generators Name and Mailing Address Generators Site Address (it di@anlm than <br />mailing address) <br />Central V31ley Waste SeMoe <br />133 East Tumer Road <br />Lodi, CA 35240 <br />Generators Phone: 204369-8274 <br />6. Transporter I Company Name <br />U.S. EPA ID Number <br />7' <br />v <br />1. Transporter 2 Company Name <br />U.. E A Iumber <br />a.Dei€�i �a�Oa�JaAddre{Ir <br />U.S. EPA CIANu1900646117 <br />35251 Old Skyline Road <br />Xettleman Chy, CA 93239 <br />Facittys Phone: 559-9711 <br />ga <br />9b. U.S. DOT Description (including Proper Shipping Name. Harard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. <br />Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if amyl) <br />Quantity <br />W2Nol. <br />I. Non-RCRA 43zardous Waste, Solid (Goll wnn lead) <br />1 <br />OT <br />18 <br />Y <br />811 <br />Ed <br />0 <br />W <br />` <br />3. <br />4. <br />14. seal H dling Instructions and Additional Infomwtim <br />ea Proper Clothing When Handling Mateflal. <br />ER 1f WA <br />Pf�nie m. CA296562 (6011 MV. 122d" <br />I GENERATOR'SIOFFEROR'S CERTIFICATION: I hemby am that the contents of this consignment are fulty and accurately described above <br />by the proper shipping name, and are classified, packaged, <br />marked and labeledlplacamed, and are in all respectsroper condidon for transport according to applicable international and national gavemmemal reguletidns. If export shipment and <br />l am the Primary <br />Exporter, I oddly that the contents of tide consign conform to the terms of the attached EPA Acknowledgment of Consent. <br />certily that the waste minimiration state en ' nbfied in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Genera st me PdnadliTyped Name Signature <br />Month Day Year <br />F <br />16. International Shipments ❑Import to U.S. Expos ham U.S. Port of entry/exit <br />2 <br />Transporter signature (for exports only): Date leaving U.S.: <br />Ce <br />17. Transporter Acknowledgment of Receipt of Materials <br />�w <br />Transporter I Printed/Typed Name SignaN <br />MgpN Day �ar <br />US �V <br />a <br />vt/ <br />i <br />Q <br />Transpa er2Pdnt ypeO Name Signature <br />Month Day Year <br />K <br />r <br />19. Discrepancy <br />I <br />Ifla. DiscrepancyIMicaton Spam ❑ Quantity ❑ Type ❑ Residue <br />❑ Postal Rejection <br />❑ Full Rejection <br />Manifest Reference Number <br />lets. Alternate Faulity (or Generated <br />U.S. EPA ID Number <br />J <br />U <br />LL <br />Facilitys Phone: <br />Monty Day Year <br />w <br />ted. Signature of Alternate Facility (m Generator) <br />Q <br />2 <br />H19. <br />Harallous Waste Report Management Method Codes (i.e., codes for haramous waste treatment, disposal, and recycling systems) <br />4. <br />20. Designated Facility Owner or Operator. Certifimtion of receipt of hasardous materials covered by the manifest except as noted in Item lea <br />/ \ <br />1 <br />Printedfiyped N e Signature <br />a� <br />EMFomr&700-22(Rw.. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION SIAIC pr nwUiRED) <br />10321.0769 <br />