Laserfiche WebLink
Please print or type.(Form designed for use on elite( itch)typevWriter.) rINnmr e 0 0 0 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.ManiOtr.o <br /> WASTE MANIFEST r� , �� - <br /> 5.Generator's Name and Mailing Address Generators Site ' dress(if different than mailing address) V`1 V 2 y Z O 17 <br /> Kraart #48 2 Kmart#48G2 G 1 <br /> 2098253233 2-55 Nothgate Drive 255 Nothgate Drive MENTAL HEALTH <br /> Generators Phone: - FIA F-T.Idlyt ON <br /> 6.Transporter 1 Company Name U.S.EPA ID Number _ DEPARTMENT <br /> Sterir�j- 'Solutions <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Fadlity Name and Site AddressU.S.EPA ID Number <br /> General Environ+pr-ntal Mot, LLC <br /> 11855 White Rock Road <br /> Rancho Cordovrs, Ca 95742 <br /> Facilitys Phone: <31C3351098121 <br /> 9bDOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> 9a. No. Type <br /> Quant Quantity Wt.Nd. <br /> HM .,,U.S.d Packing Group(if any)) <br /> -2" NO i <br /> X 'UN1993, Waste Flammable liquids, n. o. 1 CF 00010 F 3� <br /> (Acetone, Alcohols), 3, PG II, ERG#128 <br /> ui <br /> ,z X 2UN1950, Waste Aerosols. [flamizable. (each not 2 CF 00027 Pr3-31 LIM <br /> exceeding 1 L capacity)] 2. 1, ERG#126 <br /> X 3UN3266. Waste Corrosive liquid, basic, 2 CF 000^29 P D002 <br /> inorganic, n. o. s. (Sodium Hydroxide, Sodium <br /> H ochlorite) B PG II E G 1 4 <br /> X 4RQ, UN30T7, Waste Environmentally hazardous 2 CF 00014 P 181 D009 <br /> substances, solid, n. a, s. (Mercury) , 9, PG <br /> 14.S 'alHandling Instructions and Additional Information 1. 100908(Flammable Liquids) 2. 100901(Ae r o s o 1 s) 3. 100906(Basi c <br /> Liquids, Corrosive) 4. 101E16(Mercury Containing Waste) <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fuhy and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.N 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 certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am ntity generator)is true. Month ay ear <br /> Ge to rocs me ame gna re <br /> 09 1 108 12017 <br /> .International Shipments Import to U.S. ❑Export S. Port of /exit: <br /> U.S.: <br /> Transporter signature for exports only): <br /> 17.Transporter Acknowledgment of Receipt of Materialson ay ear <br /> Transporter 1 Printed/Typed yped Name a <br /> � 09 I Oa b01 <br /> Anthonv Mack ear <br /> QTransporter 2 Pr yped Name <br /> rY <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space [:1 quantity �Type <br /> ❑Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> 18b.Alternate Facility(or Generator) <br /> V <br /> Fadli s Phone: Month Day Year <br /> 0 18c.Signature of Alternate Facility(or Generator) <br /> W <br /> Q <br /> Z <br /> S2 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste <br /> (treatment disposal,and regdin systems) <br /> \ 3 4. <br /> U) 1 2. <br /> LLJ O <br /> 20.Designat a.1 Owner or operat r.Certification of receipt of haza materals covered by the manifest a as noted i em 18a pay Year <br /> Signa <br /> Print Name <br /> /1 1 <br /> EPA Form 8700 2 (Rev.3-05) Previous editions are obsolete. ESIGNATED FACILITY T TINATION STATE(IF REQUIRED) <br /> nn.*man -r :_nanr.n. 1 <br />