COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

7-185-01 Please print or type. (Form designed for use on elite (12 -pitch) typewriter.) DTSCAOS19.1198 Form Approved, OMB No. 2050-0039 EPA Form 8700.22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) 1)0012627 2) 0013906 3) 4) 10275.0610 UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response one 4. Manifest Tracking Number WASTE MANIFEST CAD981638018 1001027795 SKS 1_ 5, Generators Name and Mailing Address Generators Site Address (if different than mailing address) MIRACLE MILE DRY CLEANERS 82 W CASTLE ST STOCKTON CA 95204 Generators Phone: 209-464-0411 6. Transporter 1 Company Name U.S. EPA ID Number SAFETY-KLEEN SYSTEMS, INC. / TXR000050930 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address SAFETY-KLEEN SYSTEMS, INC. 000760 U.S. EPA ID Number 6000 88TH STREET SACRAMENTO CA 95828 916-386-4913 CA0000084517 Fadlitys Phone: 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13, Waste Codes No. Type HM and Packing Group (if any)) Quantity Wt.Nol. o X1 WASTE TOXIC LIQUID,ORGANIC N.O.S. DF P F00 D00 D039 0 (TETRACHLOROETHYLENE, TRICHLOROETHYLENE) VS -0 6.1 UN2810 PGIII RQ(FO02) 7 D04@ 741 LU X2 WASTE TOXIC LIQUID, ORGANIC, N.O.S. DF P FOO2 D007 D039 (TETRACHLOROETHYLENE,TRICHLOROETHYLENE) D04 741 6,1 UN2810 PGIII Z S0 3. 4. 14. Special Handling Instructions and Additional Information SK T R C K# 10 9 2 8 6 2 5 2 0002508564 1)ERG#153;2)ERG#153 15. GEN ERATOR'SIOFFEROR'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 labelediplacarded, and are in all respects in proper condition for transport according to applicable intemational 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 Nat the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (I I am a small quantity generator) is true. Generators/Offerors Printed7Typed Name Signal ure Month Day Year 0 —j 16. International Shipme is Import to U.S. ❑ Export from U.S. Port o trylexit: Transporter signature (for exports only): Date leaving U.S.: W 17. Transporter Acknowledgment of Receipt of Materials Transporter ted/Typed Name Signature Month Day Year ZZ Transporter 2 Pdntedrryped Name Signature Month Day Year r 18. Discrepancy 18a, Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Altemate Facility (or Generator) U.S. EPA ID Number J U LL Facility's Phone: W 18c. Signature of Alternate Facility (or Generator) Month Day Year Q 7 Z y19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) UJ C31 H141 2. M141 3. a. 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a F r nted/Typed Name ( S g ahu � Month Day Year Cl /vl C,&0<< 10141 lb� EPA Form 8700.22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) 1)0012627 2) 0013906 3) 4) 10275.0610