COMPLIANCE INFO PRE 2019 - Laserfiche WebLink

Home Browse Search

"Generator,mall a copy to:D,-,;,P.O.Box 400,Sacramerdb,C^'A W12-44W wfttdn X,daVa- Please print or type, Form dealgied for use on elite 12-pitch typewriter.) Form Approved.OMB No,2050-00 9 UNIFORM HAXARDOU8 1•Genemior ID Number 2.Page 1 of 3,Emergency Response Phone 4,Manifest Trooking Number, ? k WASTE MANIFEST v _ I-M-4 4 JJ K 6.Generators Name and Mating Address y,,y,3 � � � p Generator's SueAddross(if different Than malling address) E Generators Phone; 6.Transporter 1 Company Name U.S.EPA ID Number Evergreen Environmental Services CADM1 7.Tm rter2 Co any Nemo U.S.EPA ID Number r1lean F arbors Environmental Services, Inc MAD03932Z250 8,Designated Fadltty Now and Site Acdrseo U.S.EPA ID Number Clean Harbors San Jose,LLC 1Q21 9e7yessa Rd,, San Jose, CA; 95133 ° CA0069494310'. Facilliys Phone: 400-451-OM .. 99, 91b.U.S.DOT Description(Indudirg Proper SNpping Name,Hazard Class,ID Number, 10.Contalrers t.Total 12.Unit HM and Packing Group(If any)) t3.Was1e Codes No. Typo Quantity VAIVN. o X '' LIMM,WASTE AEROSOLS,2.1,(Ltd. Qty.) 331 DW1 w 2. 0 3 4. i 14.Special Handling Instructions and Additional Inionnabon 991)Profile*CH43Q53H, ERG*128u''� �i z' --<'" 7"R 3�S -7T 'FS'2 16 Po#3S $S, 16. GENERATOR'SIOFFEROWS CERTIFICATION: I hereby dedare that the contents of this conslgnmant are tiny and accurately described above by the proper shipping name,and aro classified,packagod, marked and lebeledlplacardod,and aro In all respects in proper oondtion for transport according Ic applicable intemalicnai and notkxrel govemmental regulations.tf export shipment and I am the Primary Exporter,I comfy that tho contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consort, I certify that the weato minimb(Ion statement identified In 40 CFR 262.27(x)(H I am a large quantity generator)or(b)(If I am a small quantity generator)is true. Generators101feror's Pentads-M N s Signature Month De Inte a5oaal Shipments IIII F ❑Impat to U.S. ❑Export from U.S. Port of entrylexlt: Transporter signature(for exports only): Date losvrg U.5.; 02"V.Transporter Acknoeho]gmonl of Receipt of Materials i rar>sporter 11.Prtntad/Typod Name SI Month Day Yepr �J'062V--457-111Z- '471'�—, Transporter 2 Printed/T ped Nama Signab;re onth De Y 113.Dbaepancy 18a Discrepancy Indication Space Q Quantity ❑Type L I Rasldue ❑Partlal Ro.c9on Ful Rejection i Manifest Refaremo Number. 18b.Alternate Fadlity(orGenarsa) U.S.EPA ID Number I u LL Facllty's Phone: aa 180.4nature ofNlomate Fac.Ity or Generator) Month Day Y, X 19.Hazardous Wasto Report Msragement Method Codes(I.a.,codes for hazardous waste treatment,disposal,and recyding systems) ,. l T/ 2. 3 a. 20.Designated Facility Owner or Operator:Certilicallon of recolpt of hazardous materials covered by the manrTest except as ctod In Item 16a Pr1n ypedNpme, � Signature � n Mont) Day Y/etv.i EPA Form 8700.22(Rev,3.05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTIN ON STATE(IF REQUIRE )