COMPLIANCE INFO_2020 - Laserfiche WebLink

Home Browse Search

i Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST C AR00027832 87 57.2869013658224 F L E 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Dollar General #11'43 7 Dollar General#1335. 2CA92531664 1201 WEST MAIN STREET 1121211 WEST MAIN STREEI RIPON, CA 95366-3 027 R 3 PON, CA 95366-3027 Generator's Phone: 6.Transporter 1 Company Name U.S.EPA ID Number Ster;cycle Specialty Waste 'olutions Inc MNS000110924 7.Transporter 2 Company Name U.S.EPA ID Number P .1 8.Designated Facility Name and Site Address 5 U.S.EPA ID Number 11855 White Rock Road Rancho Cordova, CA 95742 Facility's Phone-91835109801 ICAD9808844183 ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. K N1950, Waste Aerosols, flammable 2. 1, ERG#128 1 C:L- 00016 P 331 DOL41 0 z 2. W 3. 4. 14.Special Handling Instructions and Additional Information 1. 110541 (Aerosols) 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,aryl are classified,packaged, marked and labeled/placarded,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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b (ifI am a small q a itygenerator)is true. GeneratoeslOfferoes PrintedlTy Name Signature Month Day Year ya 08 23 019 16.Intemationa hipments F, ❑Import to U.S. ❑Export from U.S. Port of entrylexit: ? Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Uj Transporter 1 Printed/Typed Name Signature Month Day Year GO Jared Marciel 108 1 23 P019 U) Transporter 2 Printedrryped Name Soeure Month Day Year t- 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 2. 3. 4. 20,Designated Facility Owner or Operator:Certification of receipt of haiRrdous materials covered by the manifest except as noted in Item PrintedlTyped Name Signa Month Day Year form 8700-22(Rev.12-17) Previous editions are obsolete. DE TED FACILITY TO EPA's a-MA (FEST SYSTEM .22 12v3 CAL20072032 S41053271 041514192 M PDO82319 SDO82319