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ARCHIVED REPORTS XR0000359
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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BENJAMIN HOLT
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2905
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3500 - Local Oversight Program
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PR0544110
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ARCHIVED REPORTS XR0000359
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Entry Properties
Last modified
2/7/2019 9:59:06 AM
Creation date
2/7/2019 8:37:44 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
3500 - Local Oversight Program
File Section
ARCHIVED REPORTS
FileName_PostFix
XR0000359
RECORD_ID
PR0544110
PE
3528
FACILITY_ID
FA0003712
FACILITY_NAME
CHEVRON STATION #94275*
STREET_NUMBER
2905
Direction
W
STREET_NAME
BENJAMIN HOLT
STREET_TYPE
DR
City
STOCKTON
Zip
95207
APN
09760004
CURRENT_STATUS
02
SITE_LOCATION
2905 W BENJAMIN HOLT DR
P_LOCATION
01
P_DISTRICT
002
QC Status
Approved
Scanner
WNg
Tags
EHD - Public
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;ion <br /> NON-HAZARDOYS SPECAk WASTE & ASBESTOS MANIFEST <br /> If waste is asbestos waste,complete Sections I,11 111 and IV No. 0©G7C9if waste IS NQT asbestos waste complete only Sections 1 11 and III �Y .1 C3 I GENERATOR (Generator completes all of Section 1) <br /> a Generator Name (.�: ~t 5l�-' <br /> b Generating Location <br /> c Address d Address �� , ;rL ? r Or .L, <br /> e Phone No f Phone No y <br /> If owner of the generating facility differs from the generator,provide <br /> g Owners Name h Owner s Phone No <br /> TYPE <br /> BFI WASTE CODE Ju Containers DM-METAL DRUM <br /> DP -PLASTIC DRUM <br /> B -BAG <br /> 1 Description of Waste k Quandt Units No TYPE BA -6 MIL PLASTIC B, <br /> or WRAP <br /> m O -OTHER <br /> GENERATOR S CERTIFICATION I hereby certify that the above named material is not a hazardous waste as defined by 40 CFR Part 261 or UNITS <br /> any applicable state taw has been property described classified and packaged and is in proper condition for transportation according to P -POUNDS <br /> applicable regulations AND if the waste is a treatment residue of a previously restricted hazardous waste subject to the Land Disposal Y -YARDS <br /> Restrictions I certify and warrant that the waste has been treated in accordance with irle requirements of 40 CFR Part 266 and is no longer a M' -CUBIC METERS <br /> hazardous waste as defined by 40 CFR Part 261 f �' Y3 -CUBIC YARDS <br /> ,I��� rl�C,►f%Ir�J'� 'r�rf ��f� r� � rti � � O -OTHER <br /> Generator Authorized Agent Name Signature / Shipment Date <br /> Section II TRANSPORTER /Generator coin ete a d, Transporter I complete e-g <br /> t Pt Trans rte,11 coin tete h n <br /> TRANSPORTERI TRANSPORTERII <br /> 4%me ALL►lASTE TRA1dSPOI.,TAT1ON h Name <br /> b Address I`475 LIAGAS I-VE JL` t Address <br /> SAN NrAT N, CA ! i� <br /> I/ <br /> r• r- i � �� r <br /> c Dnver Name/Title �(� ♦ :`�' ►'t 1 Enver Name/Title <br /> PRINTiTYPE PRINT/TYPE <br /> d Phone No �� / 1 e Truck No k Phone No / I Truck No <br /> f Vey0e License NodState d-, / m Vehicle License NodState <br /> A�knowled ement of Rgceipt of Materials Acknowledgement of Receipt of Materials <br /> Driver Si nature Shi merit Date Driver Signature Shi t Date <br /> Section III DESTINATION (Generator completes a-d destination site completes e-i) <br /> a Site Name ' ' c Phone No <br /> b Physical Address d Mailing Address <br /> e Discrepancy Indication Space <br /> hereby certify that the above named matenal has been accepted and to the best of my knowledge the foregoing is true and accurate <br /> '� r / j <br /> Name of Authorized Agent Signature / — Receipt Date <br /> fon N ASBESTOS (Generator a-d t',g,Operator'completes e} <br /> a Operator's'Name b Operator's`Phone No <br /> c Operator's'Address <br /> d Special Handling Instructions and additional information <br /> OPERATORS CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are class <br /> packed marked and labeled,and are in all respects to proper condition for transport by highway according to applicable international and government regulations <br />
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