Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAD981460033 1 888-423-6= 008876301 J J K <br /> 5.Generators Name and Malting Address Generator's Site Address(If different than mailing address) <br /> Shell Oil Products US c/o CRA Atte: Derek Eisman 4315 Waterloo Road <br /> 6520 Corporate[?rive,Indlanepoft,IN 46278 Stockton,CA 95205 <br /> Generators Phone: 317-291-7007 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> American Integrated Services, Inc. CAR000148338 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> DeMenno Kerdoon <br /> 2000 N Alameda Street, Compton CA 90222 CAT080013352 <br /> Facility's Phone: 31 x-537-7100 <br /> ga• 9b.U.S.DOT Description(includ ng Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Tolal 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WtNol. <br /> 1• 122 DOG2. <br /> RQ,UN1760,WASTE CORROSIVE LIQUID,n.o.s.,(deco <br /> water with grout),8, PGII, (D002)ERG#154 DM t3 <br /> z 2. <br /> W <br /> 0 <br /> . i <br /> I <br /> 3. +i <br /> I <br /> 4. I ) <br /> I I <br /> I <br /> � I <br /> 14.Special Handling Instructions and Additional Information <br /> Wear protective equipment whiff handling. ights or voluOmes RIP #: 103496 SAP#100083T7 <br /> are approximate. 24 hour emergency number(800)42449300 Incident#: 98996183 <br /> Chemirec.Decon WpIter Mh Grout <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately descf be above q the proper s ppping name,and are dassl ie ,packaged, <br /> marked and labeledfplacarded,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 <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of nse <br /> I certify that the waste minimizalion statement identified in 40 CFR 262.27(a)(it 1 am a large quantity generator)or (if m a all quantity generator)is[rue. <br /> Generalors/Offerors Printedrr ed Name signature Mo th Day Year <br /> AIS on behaGIF SOPUS-J Sherman ao <br /> j 16.International Shipments <br /> F ❑Import to U.S. Export from U.S. Port of entry/exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> 1* Transporter 1 PrintedfTyped Name Signature Month Day Year <br /> �' . <br /> CL <br /> Si Month Da /Year <br /> z Transpprt 2 Printed/Typed Name Signature 7 <br /> r- <br /> 18.DIlicrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> ra+- Facility's Phone: Manlh Day Year <br /> w i8c.Signature of Alternate Facility(or Generator) <br /> a <br /> z <br /> m19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste I(ealment,disposal,and recycling systems) <br /> o t, 2. <br /> 3. 4. <br /> 46 <br /> 20,Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Print /Typed Name Signa Month Day Year <br /> AFor ,700-22(Rev.3-05) Previo s eflItions are obsolete. DL5IGN,A7Cq t61-111 ITY O U[SYINA ION STP:4'1- OF Aia'UI1'1 j <br /> i <br />