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CO0037859
EnvironmentalHealth
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2500 – Emergency Response Program
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CO0037859
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Entry Properties
Last modified
2/16/2021 5:20:15 PM
Creation date
2/12/2019 1:25:00 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2500 – Emergency Response Program
RECORD_ID
CO0037859
PE
2546
STREET_NUMBER
161
Direction
E
STREET_NAME
TRANSPORTATION
STREET_TYPE
CT
City
FRENCH CAMP
Zip
95231
APN
19327018
ENTERED_DATE
4/17/2014 12:00:00 AM
SITE_LOCATION
161 E TRANSPORTATION CT
RECEIVED_DATE
4/17/2014 12:00:00 AM
P_LOCATION
99
P_DISTRICT
003
QC Status
Approved
Scanner
ADMIN
Supplemental fields
FilePath
\MIGRATIONS\T\TRANSPORTATION\161\CO0037859.PDF
Tags
EHD - Public
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Please print or typo.(Form designed for use on elite(12-pkch)typewriter.) <br /> If UMFf?f1M HAZARDpUS t Ge rrrat x fD Ifirn w Form Approved_GMB No. <br /> �� 2 Page 1 of 3.�y Response Phone 4.manifest TfarkFngNumber <br /> WASTEMANIFl=ST � ty•?� 1�a005231780 <br /> g r <br /> 5.Gsneratos's Name and Ma ling Address <br /> ����(fir n CienereialsSifeAddress <br /> J�-!4�J�rlf�Jle��.L (+fd'mercnt!horn ma=.Crtg address! <br /> 3 U 'Rc c►nrD�r 1(0! �f}s 1 7kAx,5Po TtvM (',T. <br /> GeR5N SAY,of fES 3l3 <br /> GeniarawsPhare: CA CA F', S 3 I <br /> 8.In a11! 1 Ccunpar i Name C <br /> MOXA0 C-mul kip1l} J T U.S.EPA <br /> +ID Num"v(�er �j�/ <br /> 7.Trarsporbr 2 Company f tame f C) V0 I✓ +Z-s.(� <br /> ! 0 <br /> U-S.EPA ID Number <br /> B Da grsaled H= Rely Name and SiteAddress a 0 C I <br /> US.EPA ID Number <br /> NaXICA-4061-3 <br /> FacWsPhmw: <br /> 9a 9b.U.S.DOT©RS ion[mckfding Prolier 5hi <br /> Pp n9 Name,Hazard Class ID FJumb�, E <br /> HM and Pal{Troup(f aryl18.Containers S f.To+al f 12.Unit <br /> No, Tye Q1ant tY +I 'NE1Val. f3.Waste <br /> 03 DM 120o <br /> Z 2. 3S <br /> 3, E <br /> I <br /> 4. j <br /> �I <br /> id.Spatia Handl ng lost rctons acrd Additional m a <br /> { q Tfl�ck->! OJ�1' o as5e5- <br /> 15. GEfdERflTr)R'S10FF9tpR S CEll 711:1 AT1l)N:t herabydedam that itw contents of Stas conr<gnment are <br /> marked and 1"ed)rplacarded,and are in art respects in a and acamtely dzscrrbed above bytire prapzr sfu�rstg name.aryl are dass€ded,pa�u <br /> sp pmp f cor3ditiatiortrarfsport a=ldiag to appkabla hematbradardl national gavemman�regulations.If export shipment and Ian the Prim <br /> Exporter.t omtify that the conttents of ft consignment conform to the loris of the attached FPAAdetowledgment of Consent. <br /> r cerfTf}that ftle waste minimrzatwn sbtantent iderfiled in 40 CFR 2E2-27(a)if I am a lar a uan <br /> {) g qui geneuafor}of(b smat quantify generator)is into. <br /> Genaralrr>' erot's PdntedlTypt<ci Narna <br /> r/ .1i ! bl[cntth Day <br /> __.r 18.4nterna5orra13hipmenU- ��ll <br /> Importfo U.S. lJ Export from U.S. Pon of mifryfefa€ <br /> Tiatrspottafs�naiure(iwexportsonty): <br /> i7 T DaL leaving U S <br /> W rarrporterRdmowisdgrrtar#�Receipt�Mai�Mials <br /> Transporter 1 Pr nfodlTyped Name SignalfV0 1' r MYan(fi/ Day ie <br /> Transporf� Pr'ntea yped Name <br /> -ftirwre ✓ ! T <br /> McWLh Da! ' y_ <br /> 18.bacrepaney <br /> lea Dsuepanty Indication Space <br /> ❑ Quantity ❑Typo E J <br /> IJ Portia!Rejecticn Q Fon <br /> p <br /> Bb.Altenrate Fait' <br /> for General hfanifesP Refa once Number: <br /> General <br /> U.S.EPA tD Number <br /> c� <br /> Fad[Vs frill <br /> Lu ilk.Slgnahare at Marinate Faaky(of Generator) <br /> floni Day Y <br /> 11 I <br /> co19 flora duos Wastes Report Management Method Codes{:e,codesforhnardous waste treatmentdispel.and ams) <br /> In 1. 2- 3 <br /> y. <br /> 2D.Designated Fal DNner or operator Cerflf cation of repripf of frezardous malera35 coverei fry the marurest eurcpl as nc6d n turn lea <br /> PriatedrTyp�Name Signature <br /> Atomh Y r <br /> EPA Form 8700L 22(f�ev.3-05) Previous adlTio>3s are nbsafete. <br /> _-3 --A ED F--+: '!TO R�� <br />
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