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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
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WNg
Tags
EHD - Public
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;ection <br /> NON-HAZARDOUS SPECIAL WASTE-& ASBESTOS MANIFEST <br /> IF <br /> If waste is asbestos waste,complete Sections 1 Il III and IV _! ofl [7?`�If waste Is'NN T asbestos waste,complete only Sections 1 II and 11i V lS 7 ( i I GENERATOR (Generator completes all of Section 1) <br /> Cr1EV1~Ol; St t's.ul. <br /> a Generator Name b Generating Location <br /> an <br /> c Address d Address `"15 j-,E, 3 t1. E�E1L , i r,C'�� j.FI u ' <br /> �1:�i_1.TGN �,� <br /> e Phone No f Phone No <br /> If owner of the generating facility differs from the generator provide <br /> g Owners Name h Owner's Phone No <br /> TYPE <br /> i BFI WASTE CODE 1 Containers DM-METAL DRUM <br /> OP -PLASTIC DRUM <br /> B BAG <br /> I Description of Waste k Ouantil Units No TYPE BA -6 MIL PLASTIC f <br /> or WRAP <br /> T TRUCK <br /> O -OTHER <br /> GENERATORS 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 law has been properly described classified and packaged and is in proper conddion for transportation according to P -POUNDS <br /> applicable regulations AND,if the waste is a treatment residue of a previously restricted hazardous waste sublecl to the Land Disposal Y YARDS <br /> Restrictions f certify and warrant that the waste has been treated in accordance with theFequirements of 40 CFR Part 268 and is no longer a M' CUBIC METERS <br /> hazardous waste as defined by 40 CFR Part 281 �,.., <br /> J Y3 -CUBIC YARDS <br /> !� O -OTHER <br /> Generator Authorized Agent Name Sigifiature Shipment Date <br /> Transpofter 1 complete e� <br /> Section H TRANSPORTER (Generator complete a-d Trans rter I Dorn tete h-n <br /> TRANSPORTERI TRANSPORTERII <br /> 01•Name ALL,I«STL 'TRAM SiPOPTAT LON h Name <br /> b Address 1241—' LI_AGA` AVY IOU t; i Address <br /> c Driver Namefritle i: ":.do 1A liq<,`a en C., 1 Driver Name/Title �f <br /> PRINT PE PRINTltYPE <br /> d Phone No t 4`�' 2 ' `�Q e Truck No L 1 ; k Phone No I Truck No <br /> `".` is L J m Vehicle License NoJState <br /> I Vehicle License NoJState �� � t � <br /> Acknowledgement of Receipt of Materials Acknowledgement of Receipt of Materials <br /> g Driver Si r Fure y .�` / Shipment Date Omer Signature Shipment Date <br /> Section III Y DESTINATION (Generator completes a-d destination site completes e-1) <br /> a Site Name `f` f� ' c Phone No <br /> b Physical Address ' ' acfJr! j d Mailing Address <br /> e Discrepancy Indication Space <br /> I hereby certify that the above named material has been accepted and to the best of my knowledge the foregoing is true and accurate <br /> f Name of Authorized Agent Signature Receipt Date <br /> jftction IV ASBESTOS (Generator complete a-d,f,g,operator'oompietes e) <br /> a Operator's'Name b Operator's`Phone No <br /> I <br /> c Operators`Address <br /> d Special Handling Instructions and additional information <br /> OPERATOR'S CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are cia <br /> packed,marked and labeled,and are in all respects in proper condition for transport by highway according to appllcabte international and government regulations <br />
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