Laserfiche WebLink
i <br /> DTSI_. 0 G . l' 82IJ <br /> 0 <br /> 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 Number 2,Page 1 of 3.Emergency Response Phone an'rfest Tracking Number <br /> r014378725 <br /> WASTE MANIFEST NRC 510-749-1390 JJ K <br /> 5.Generators Name and Mailing Address Att CYNTHIAADKI55ON Generators Site Address(if different than mailing address) <br /> EAST BAY MUD EAST BAY MUD <br /> P.O.BOX 24055,MS 704 25724 N.McINTIRE RD. <br /> OAKLAND CA 94623-1055 CLEMENTS CA 95227 <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> NRC ENVIRONMENTAL SERVICES INC. IC A R 0 0 0 0 3 0 1 1 4 <br /> 7.Transporter 2 Company Name �[ U.S.EPA ID <br /> Number <br /> _^ ✓'! w S 1 L ! 2 rY s a/��Y I L QK 7q <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Crosby&Overton,Inc. <br /> 1830 W. 17th Street <br /> Long Beach CA 90813 <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) <br /> No. Type Quantity WWoI. <br /> 0 <br /> 1- IN 0 N -RE t� A 7-AKD n LAS W A-5-re <br /> SOL-10 010 PC-bk[S 001 D 223 <br /> z 2. <br /> W <br /> 0 1—] <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information �n „�,r <br /> WEAR APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT 332-n D 121 2_f�`�;�KEv� <br /> 248HR EMERGENCY ENCY CONTACTPONRC ENVIRONMENTAL SERVICES INC. 510-749-1390 Y 7�Ho 0S9 <br /> 15. GENERATOR'S10FFEROR'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, <br /> marked and labeled/placarded,and are In all respects in proper condition for transport according to applicable international and national govemmenal 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 Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity gen tor) ( ' I am a smill quantity generator)is true. <br /> GeneratorslOf(eroes Printed/Typed Name Sig Month Day Year <br /> 12 JJ I ii <br /> 16.International Ship nts Import to U.S. try <br /> ❑ Export from U.S. Port of en /exft: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> LW 17.Transporter Acknowledgment of Receipt of Materials <br /> LW <br /> Transporter 1 PdntedfTyped Name Signature Month Day Year <br /> CL S�tiD L I �1 �S <br /> Z Transporter 2 Printed(Typed Name, Signature Month Day Year <br /> Cut <br /> 18. <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity Type ❑ ❑ 1 ❑ J <br /> ❑T Residue Partial Rejection Full Rejection <br /> l <br /> — -Man'est Reference Number. <br /> 18b.Altemate Facility(or Generator) + }Z1+• 3 w - — U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility s Phone: Y 0 4 2016 <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a - min - <br /> z <br /> ti <br /> 19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment disposal,and recycling systems) <br /> w 1 �� 2. 3.+� 4. <br /> G <br /> 20.Designated Facility r or Operator.Certification of receipt of hazardous mqVnals kovpred by the manifest except as noted in Item 18a <br /> Printed/Typed NS gnaiure Month Day Year <br /> Y I���ISSStttIJJJ1� Z / <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> 12196.1885 <br />