COMPLIANCE INFO PRE 2019 - Laserfiche WebLink

Home Browse Search

Please print or type. (Form designed for use on elite (12 -pitch) ty I ' I UNIFORM HAZARDOUS 11. Generator ID Number I I WASTE MANIFEST C A 6 5 7 2 F I enerators Name and Mailing Address Stockton CSMS III8020SouthAirport Way Generator's Phone's t0�7ii"c7 n 4 R?- G, 4 C r 6. Transporter 1 Comoanv Name Form Approved. OMB No. 2050-0039 1 of 3. Emergency Response Phone 14. Manifest Tracking Number (562) 984-8178 007735534 JJK Generator's Site Address (if different than mailing address) CA 95.206-399 U.S. 3. 4. I I I I I ' I I I Special Handling Instructions and Additional Information 1 t ,.• _ken L nr.: s PRE#f 44444 F9GO t7lt E1 LL Tq: fX vACL'i1Nt Work Or3er: 4437.0 r04 SF- 4500-06-1)-0014-12 3.1 15. GENERATOR'S#OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity gen tor) or (b) (if I am a s ntity rier or) is true. Generator fferors Print yped me gnat Month Day 16. Intemdfional Shipments! 1-- 1:1 Import to U.S. ❑ Export from U.Sl. Port of entry/exit. Transporter signature (for exports only): I Date leaving U.S.: LU 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintedTryped Name Signature o y^' eA !f .s QTransporter 2 Printediped Name 1 ` Signature 18. Discrepancy 18a. Discrepancy Indication Space ❑ quantity ❑ Type 18b. Alternate Facility (or Generator) Facility's Phone: W .18c. 'gnature of Alternate F;cility [Generator) 9. Hazardous Waste Report Mana�iriient Meth d Codes (i.e.. codes for hazardous waste treatment, disposal, and 2. 3. 20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest• e Printed/lyped Name 7. -Signa r EPA Form 8700-22 (Rev. 3-05)' revious editions are obsolete. Qz. Ya: ❑ Residue ❑ Partial Rejection Month Day ❑ Full Rejection 4. as noted in Item 1 :. f 1 DESIGNATED FACILITY TO GENERATOR 7. Transporter 2 Company Name 8. Designated Facility Name and Site Address U.S. EPA ID Number Lighting Resources, LLC (IN) I N 0 0 0 0 3 5 1 2 8- 498 Park 800 Dr. Facility's R&@Pwwood 614? - IN 4614-1- 9a. 9a. 9b. U.S. DOT Description (including Proper hipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group if an 9 P C Y)) Quanti ty WtWol. t. (—� ,' i ' 00 V1 RQ) Waste;, Mercury, 8, UN2809, IT 1%broket7 , � F 7:_-) - lamp.m) DI) n_° Z 2. 3. 4. I I I I I ' I I I Special Handling Instructions and Additional Information 1 t ,.• _ken L nr.: s PRE#f 44444 F9GO t7lt E1 LL Tq: fX vACL'i1Nt Work Or3er: 4437.0 r04 SF- 4500-06-1)-0014-12 3.1 15. GENERATOR'S#OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity gen tor) or (b) (if I am a s ntity rier or) is true. Generator fferors Print yped me gnat Month Day 16. Intemdfional Shipments! 1-- 1:1 Import to U.S. ❑ Export from U.Sl. Port of entry/exit. Transporter signature (for exports only): I Date leaving U.S.: LU 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintedTryped Name Signature o y^' eA !f .s QTransporter 2 Printediped Name 1 ` Signature 18. Discrepancy 18a. Discrepancy Indication Space ❑ quantity ❑ Type 18b. Alternate Facility (or Generator) Facility's Phone: W .18c. 'gnature of Alternate F;cility [Generator) 9. Hazardous Waste Report Mana�iriient Meth d Codes (i.e.. codes for hazardous waste treatment, disposal, and 2. 3. 20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest• e Printed/lyped Name 7. -Signa r EPA Form 8700-22 (Rev. 3-05)' revious editions are obsolete. Qz. Ya: ❑ Residue ❑ Partial Rejection Month Day ❑ Full Rejection 4. as noted in Item 1 :. f 1 DESIGNATED FACILITY TO GENERATOR