Laserfiche WebLink
• • DTSC. 00W). 2162 <br /> Please print or type.(Porto designed for use on elite(12-pitch)ryyewri[er.) - <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Genmtor ID Number 2.Page 1 of 3.Emergency Response Phona 4.ManNest Tracking Number <br /> WASTE MANIFEST C A C 0 0 2 6 3 8 2 5 4 (800) 424-9300 005541265 JJ K <br /> 5.Generators Name and Mailirig Adtl:miss <br /> Generators Site Address 111 diRerent than mailing adtlress) <br /> CI TY OFSTOCKTON-REDEVELOPNENTAGENCY 701 &8 W.WEBER AVE <br /> 425 N.EL DORADO ST. FL 3 <br /> STOCKTON CA, 96202 STOCKTON CA 95203 <br /> Generator's Phone: 530 878111 U.S.EPA ID Number <br /> 6.Transporter 1 Company Name <br /> ASBURY ENVIRONMENTAL SERVICESC A D 0 2 8 2 7 7 0 3 6 <br /> 7.Tweporl Company Name LLS.EPA ID Number <br /> S.Designated Facility Name and Site Address U.S.EPA ID Number <br /> DEMENNO/KERDOON <br /> 2000 NORTH ALANE0A STREET <br /> COMPTON CA 90222 C A T 0 8 0 0 1 3 3 5 2 <br /> Fecili IsPhone: 13101537'7100 <br /> ga 9b.U.S.DOT Desorption(including Proper Shipping Name,Hamm Class,ID Number, 10.Containers 11,Total 12.Unit 13,Waste Codes <br /> HM <br /> and Pai Groupe BrIM No. Type Ouentiry Wtivol. <br /> 7. <br /> NON-RCRA HAZARDOUS WASTE, LIQUID (OILY WATER) 0011 T T 150 G <br /> z 2. <br /> W <br /> 3. <br /> 4 <br /> 14.Special Handling Instructions and Additional Information <br /> NAERGff 981 : 171'PROFILE 11981 : OILY WATERAPPROPRIATE PERSONAL PROTECTIVE EQUIPMENT <br /> HB/Project#60469Al2 POOA080103345 II. <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are runy and aoaualey described above by the proper snipping name,and are tlasl packaged, <br /> marked and labeled/placarded,and are in all respects in proper condiCon for transport beco ing to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,l amfy mbar Ne contents of this consignment conform N the terns of the aaached EPAArknowledg I Consent. <br /> I artily that the wa to mini 'nation statement idenfitied in 40 CFR 262.27(a)(if I am a large quantity generator a (b)(if I am a small qu ti generator)is true. <br /> GeneratorstOrtemes I yp Name t _ p,r, F+l I,,, Signaler Monty Day Year <br /> '5 i 9 i - 01 1 1516q <br /> J 16,IntemaBonal Ship nImport to U.S. El❑ Export from US. Port of en it' — <br /> Transporter signal(for exports only): Date leaving U.S.: <br /> K 17,Trampolier AcknoWedgment of Receipt of Mal <br /> Transporter 1 PrtntedrTyped Name✓ Signature Month Day Year <br /> a �—(8� f1 P,� ®f It rj 1 09 <br /> M Transporter 2 Pnntedrryped Name Signature Monty Day Year <br /> 6 <br /> C <br /> r <br /> 18.Discrepancy �I <br /> 19a.Discrepancy Indication Spam ❑ Quantlty ❑Type ❑Residue QPaNal Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 18b,Allemefe Fall(or Ganeraror) U.S.EPA ID Number <br /> J ' <br /> U <br /> LL Fadlilys hone: <br /> w 1Bc.SignaPNre of Abemate Facility(or GeneretoQ Monty Day Year <br /> Q <br /> 2 <br /> y79.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment tlispasal,and reading systems) ' <br /> 1 w 2. 3. 4. <br /> 20.Designated Facility Owner or Operator Certification of receipt of hmrdous materials covered by the manifesntyeexcept as mould in Item 1 as <br /> 1 partial Name Sgn month Day Year <br /> ��Y/11/1/ 200 I <br /> EPAForm 01}22(Rev.3-05) Previous edii am obsolete. DESIGNATED FACILITY T DESTINATION STATE(IF REQUIRED) <br /> 10490.0500 <br />