Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone Manifest Tracking Number <br /> WASTE MANIFEST 4. 4.1 (916) 371-5747 JJK <br /> 5.Genera s ame and Mailing Address Generator's Site Address(d different than mailing address) <br /> SH6Lr- X--S- <br /> 70 <br /> -s <br /> 70 1"' sr. <br /> {yy,�.�j,�4 .9.2646 <br /> GErniT3T%Phone. <br /> 6.Transporter 1 Compby Name U.S.EPA ID Number <br /> RAMOS ENVIRONMENTAL SERVICES CAD 044 003 556 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> RAMOS ENVIRONMENTAL SERVICES <br /> 1515 SOUTH RIVER ROAD, WEST SACRAMENTO, CA 95691 <br /> Facility's Phone: (916) 371-5747 CAD 044 003 556 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group Cif any)) No. Type Quantity. WlNol. - - - <br /> 1 NON—RCRA HAZARDOUS WASTE LIQUID 223 <br /> 0 (OILY WATER) <br /> 01 <br /> Z 2. <br /> w <br /> 3. <br /> 4. <br /> 14.Speaal Handling instructions and Additional Infornaton ERG04#171 <br /> 9bl) <br /> HANDLERS TO BE TRAINED AND USE PPE. <br /> 15. ENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described 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 EPAAcknowledgment of Consent <br /> 1 certify that the waste minimization statement identified in 40 CFR 262.27(a)(H I am a large quantity generator)or(b)(if I am a II quantity generator) e. <br /> GeneretorslONeror s Pr me ed N me Signature Month Day Year <br /> J , lV r-7-12-,4/L,/ l !g o6 <br /> .1 16.Intemational Shipments <br /> F ❑Import to U.S. ❑Export from U.S. Port of enbylexit <br /> Z Transporter signature(for exports only): Date leav ng U.S.: <br /> K 17.Transporter Acknowledgment of Receipt of Materials <br /> ir Transporter 1 Printed/Typed Name Signature Month Day Year <br /> 01 /1 Ij,5104 <br /> " - <br /> N 0 Month Da Year <br /> Z Transporter 2 PrintedlTyped Name Signature y <br /> t- <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space ❑ Quantity [:]Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> 7 <br /> U <br /> LL Facility's Phone: <br /> 0 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> D 1. ` 2' 3• 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials cove4 by the manifest excep noted in Item I as <br /> Pri a Signature Mpn Day r <br /> 7 _V-%j I <br /> EPA Form 8700-2 ev.3-05) Previous editions are obsolete. DES GNAT A N STATE/ <br /> (IF REQUIRED) <br /> 10076.0208 <br />