Laserfiche WebLink
Please print or type. <br /> UNIFORM HAZr4R170US 1.Generator lD Number 2.Page 1 of 3,Eme enc Res Form Approved.OMB No.2050-0039 <br /> WASTE MANIFEST C A I G U fi 4[!8 Ipnse Plrone 4 Manifest Tracking Numf>er <br /> JJK5.GeIr�iprs_ Na,r $n d� Generator's Site Address(it different than mailing address) ')91967 <br /> 12988 W.MCDONAlD ROAD <br /> 1++9�irCiliAl.� F?� <br /> STOOK? N � a. <br /> Generator's Phone: 209 464-,-48th <br /> 6.Tren�pg i r�pany <br /> Fame <br /> �Y 11 UlL NVIRONMENTA?SrRIVIl U.S.EPAIDNumber <br /> 7.Tre <br /> A1) 28277036 <br /> WWW"COVERY SYSTEM im" A ID Number <br /> 5,5t)ci EIS HiGf#1NAY�5 U.S.EPA lD Number <br /> PUMA <br /> Facility's Phone: (9283 344.0828 A Z 0 l 0 0 5 2 1.14 b <br /> 9. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, <br /> HM and Packing Group 0any)) 10.Containers 11.Total 12.Unit <br /> 1NON-RCRA I{IAZARDOUS�ygQTE 13.Waste Codes <br /> 0 SOlIC,S;t.)It_Yr1Ei:itlf?QE'IVY ,', No. Type Quantity WI.NoI. <br /> r.' 352 <br /> W 2 P <br /> L7 <br /> 3. <br /> 4. <br /> 14.Special Handling Inshuctions acrd Additional Information <br /> EMERGENCY CONTACT;CHEFMTRFC �' <br /> 16=3hWTIK003 OILY * c°Vvtpi I:^14iIML t;till(S NAEFtC3N 9fs1 :111 PROFILE <br /> ROFILE M 981: <br /> ABSU#i8ENT5 AF'�TRvrrafilTt pillt�f?t.iIPMENT <br /> 18. ma ked and R'$IDFFEROR'S CERTIFICATN)N: Thereby declare lfrat the contents of Phis consignment are fully and accurately described above by the proper shipping name,and are classified, <br /> marked and laheledlplacanded,and are in all respects in proper condition for transport according to aFrplicabie intemafional and national gavemme y t <br /> Exporter.I certify that the contents of this consignment conform to the terns of the attached EPAAclmowledgment of Consent, regulations.If export shipment and I am the primary <br /> Certify that the waste minimization statement Identified in 40 CFR 262.27(a)(if t am a large quantity generator)or(b)(if am a small qua <br /> Generator'slDHeror s PdntedlTyped Name q tdy generator)is true, <br /> Signature <br /> F- 16.International Shipments Day Year <br /> ❑Import to U.S. ❑Export from U.S. Port of entrylexR; <br /> M Trarsporter signature(for exports only); <br /> rY 17.TransporterAduxw&dgment of Receipt of Metedats Date leaving U.S.: <br /> Transporter 1 PdntedlTyped Name <br /> dSignature <br /> 2 C6 Month Day Year <br /> Transpoder2 Pdntedlfyped Name <br /> Signature <br /> 18.Discrepancy Month Day Year <br /> 1 Sa.Discrepancy Indication Space ❑ Quantity <br /> ❑Type <br /> ❑Residue ❑Partial Rejection <br /> ❑Full Rejecfion <br /> 18b.Alternate Facility(ar Generator) Manifest Reference Number <br /> 0 U.S.EPA ID Number <br /> LL Facility's Phone: <br /> 16c.Sigrature of AlEemats Fadllty(or Generator) <br /> Q <br /> � Month Day Year <br /> H 19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposcl,and recycling systema) <br /> I. <br /> 2. <br /> 3. 4. <br /> 20,Designatad Facility Owner or Operator.Cer6fieation of receipt of hazardous meledals covered by the manifest except as nded in ftem 1 Be <br /> PrintedlTy)ad Name <br /> Signature <br /> Month Day Year <br /> FAA Form 8700-22(Rev.i2-17} Previous editions are obsolete, <br /> GENERATOR'S INITIAL COPY <br />