Laserfiche WebLink
Please Drint or We. (Form desianed for use an elite 112-ditchl Mewriter.1 <br />Form Approved, OMB No. 2050-0039 <br />E:PxForm lilruu-a (Rev. j-vb) vrevious elainorls are wmele. DESIGNATED FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS <br />1 - Generator ID Number <br />12. Page I of <br />1 3. Emergency Response Phone <br />14. Manifest Tracidng.Number <br />1 <br />WASTE MANIFEST <br />C A 4", 0 0 0 8 <br />('100 4,24-9j00 <br />I / <br />0 0 K39.02 JJK <br />- <br />5. Generator's Name and Maing. Address Generator's Site Address (If different than maging address) <br />HO. -r0 HCALIFORNIA (ST(XK"(-1'N.) <br />t.Q I CCASTER lMW <br />-;fi1C'RAN`E-NT0 !,A -Ij '3 TON','K fON <br />Generator's Phone: <br />6. Transporter I Company Name U.S. EPA ID Number <br />AS0URY DWRONNENTAL SERM'GESRECE Xlr= M C A b u 2 o 2 7 7 0 3 <br />-1 <br />7. Transporter 2 Company Name �T.& EPA ID Number <br />8. Designated Facility Name and Site Address MAR IL t-Ul(- U.S. EPA ID Number <br />, WIR TH ALAXEDA -UREFT <br />K00 <br />C01h;VTON CA 4krZ--" ENVIRONMENTAL HEALTr " <br />I A T 0 R Q .1 :3 :5 <br />Fa' es Phone., 0101631-7%1) PERMIT/SERVICES <br />ga, <br />9b, U.S. DOT Description (Including Proper Shipping Name, Hazard Class, ID Number, <br />10. Contahers <br />11. Total <br />12. Urit <br />13. Waste Codes <br />NO. <br />type <br />HIM <br />and Padft Group IN any)) <br />Quantity <br />WL/Vol. <br />0 <br />INASIM- F'Aj'N? 71, LIN i 226Z PG 0 <br />Z <br />2. <br />w <br />THIS WASTE STREAM HAS BEEN QUALIFIED <br />EOR 'NPAFATMENT <br />RECYC' Af:HIE <br />OeMENNO/KERDOON FACILITY IN COMPTON, <br />CALIFORNIA. THIS FACILITY HAS THE NECESSARY <br />4. PERMITS 10 KLULIVL YOUR WASTE STREAM AS <br />OUALIFIED OUR EPA NUMBER IS CAT080OLUS2 <br />14. Special Handing!nstructions and Adrifflonal Inib"nallorl <br />'981 . t2'19 1 PROALE 49EO :31272* R$01T * A-QDI*TV)NA1 WA. 1XfX-S All Nk'-)k* AP10 OPRI r�EPFR.L". <br />-tori Ft= ' R A' <br />PROIIT-017W. <br />2B I PRWECTI 63674AI5 <br />15. GENERATOR'SlOFFEROR'S CERTIFICATION; I hereby declare that the contents of this �t are fuUy and accurately described above by the proper shippin() name, and are classified, padw*, <br />marked and labelediplacarded, and are In all respects in.Koper condition for transport according to applicable internatimW and national govern ental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conb* to the term of the attached EPA AcWoMedgmert of Consent. <br />I certify that the waste mir*nIzation statement Identified In 40 CFR 262.27(s) (If I am a I&W quantity generator) or (b) (91 am a stgall We" generator) is ho. <br />Gen toes/offemrs'd Name Month Day Year <br />r" <br />1 ) I <br />7 <br />-j <br />16.1fitomational ShipmanY <br />El 1,44 to U.S. ❑ Expert from U.vr Port of <br />Transporter signature (for exports onty): Date IoavN U.S.: <br />U.1 <br />17. TransporterAddioWeclgrnervt �.ggceipt of Materials; <br />Transporter 1 Ptintecirryped2, r Month Day Year <br />0 <br />CL <br />Z <br />Transporter 2 Nnted/Typdd-ftffe Mon Day Year <br />4 <br />18. Discrepancy <br />j <br />18a. Discrepancy Indication Space ❑ Q.rtfty❑ Type El Residue D Partial Roection ❑ Full Rejection <br />Manifest Reference Number. <br />18b. Afternale Facility (or Generator) U.S- EPA ID Number <br />LL <br />Facillys Phone: <br />LU <br />18c. Slgnatunq, of Alternate Facility (or Generator) <br />Month Day Year <br />C' <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />2. <br />r <br />4. <br />1 <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials cowed by the manifest except as noted in lteraj&� <br />Printer Name SignaW- - - Month Day Year <br />Y <br />E:PxForm lilruu-a (Rev. j-vb) vrevious elainorls are wmele. DESIGNATED FACILITY TO GENERATOR <br />