Laserfiche WebLink
Jun 16 03 10:42a <br />Skste of Colliorn;c-Envirnrunarloi Protection Agency <br />Form Approved OMS No. 2050-0034 (Expires 9-30• <br />Plecee nrini ar erne. Form desietned far use on ®tits, f 12�pitch? rypewrirer. <br />C <br />n: <br />DC7; <br />VA <br />See Instructions on back loge 6. <br />p.4 <br />Department of Toxin Substances Cc <br />Sacramento Cnllfemte <br />DO NOT WRITE BELOW THIS LINE. V <br />DTSC 8022A [1/99) White: TSDF SENG5 THIS COPY TO DTSC WITHIN 30 DAYS. <br />EPA 87150--22 Tc: P.0 nix 3000, Sacramento, CA 55812 <br />1. Generator's US EPA ;D No. Monifesl Document Tient Na. <br />2. Page 1 <br />lnforma ion in the shaded areas <br />I <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST y� p �/ <br />iagri6 icii 1%� i[� 5 1.3 3 i ii <br />of <br />is not reyusr®d by federal low. <br />3. Genaroior's Some and Mailing Address <br />Gk� y .- �� s <br />A. Stet: Monlfest Document Number <br />20118330 <br />^41411d y€ <br />27 jQo•V%, C,, Co5P. gS'3.4e-df-ra <br />_ <br />g. Sbte Generalors l0 <br />1 <br />1X09 <br />A. Generalprs Phone ) — <br />1 <br />5. Transporter 1 Company Name S. US EPA 10 Nwuber <br />C. S!oteTransportar's Ip Ree d.j <br />1 <br />EVERGREEN ENVIRONMENTAL SERVICES�r� A I r� 19 41113 � Q J � + 2 <br />$ <br />D. Transporter's Phone (8®a' 072-5284 <br />1 <br />7. Transporter 2 Company Nome 3. US EPA 10 Number <br />E. State I'mnsporter's ID [Reserved.) <br />s <br />^rJ 1 � � ' Iy,__.'c--._L15.�-j a-•a'ul IJ I G' 1(J <br />F. Transporter's Phon e r+ a v� <br />J !♦ - <br />f <br />1 <br />9. Designated Facility Nome and Site re 10. US EPA ID Number <br />G State Facility's IO <br />SAFETY KLEEN (SAN JOSE) INC. <br />H. Faenlya Phone <br />1021 Berryesa Road <br />' <br />S n Jose <br />1-4DO-451.5000 _ <br />I <br />j <br />I t. US DOT Description (including Froger Shipping Name, Hazard Class, and ID Number) <br />4 <br />12 Containers <br />No. <br />Ttgo <br />13. Total <br />ouantily <br />IA Unit <br />Wilvol <br />I. Wosle Number <br />a <br />I <br />s�� 223 <br />G <br />Non-RCRA Hazardous waste, Solid <br />I <br />e? j 5{ 6 �U <br />EPA/Olher <br />Unn-RCRA <br />I fv <br />b. ---- --- --- <br />�I0 <br />State <br />E <br />R <br />l <br />EPA/Ot)wr <br />Yc. <br />�.••-.-. <br />Slate --.- <br />O <br />EPA/O16r <br />d. <br />State <br />� <br />I <br />�! <br />EPA/011ier <br />! <br />J. Additional Descriptions for Materials Listed Above <br />K. Hondlirsg es for Wastes Listed Above <br />a. b. <br />Non-RCRA Oily Debris, Profile I 1 <br />r. <br />a <br />18. Special Hancgfng Insirocgora and Additional Information <br />24 Hour Emergency Res pan oro e, No. -6 11494, err {c bili of Lading # <br />DOT Easizi-We ctivf ciothin® Z — – ?� / -� <br />leeatS as,his rcns((ate lufb end s ' <br />marked, and labeled, one are in oil respects in proper candition for tronsport y highway according too icable inrernotAane on notion government regu ofians. <br />If I am a large quantiy generator, ! cars fy that I have a program in place to reduce the volume and toxicity of waste generated Io the degree I have determined to be economically <br />and )hw I have selected the practtcabie method of Iraatment, sterane, or ditpnsol currently available tz me which minimizes the present and F.rturo threat to human health <br />practicable <br />and she enviromraert; OR, if I am a amai: quantity generator, 1 hw a made a goad illi effort ro m(nim ze my waste anerat on and select rhe beet waste management method that is <br />available to me and that I can afford. <br />Month Day Year <br />=a6,6,dig,�I' <br />OeN <br />of P.e<eipt of Materials — <br />6 <br />P -fated/ TT.yyp*dd Name <br />Signature <br />Signature <br />Month Day Year <br />S <br />�/) w., <br />I � p <br />LOIS 1j 17 <br />P <br />SS <br />-- <br />18. Trory crier 2 A .nowled ement of Receipt of Materials <br />1 <br />_ <br />Printed/Typal am � <br />� l ( /f <br />Month Day Year <br />Y <br />19. Discrepancy icahor Space ~ c✓ <br />rA <br />L <br />1 <br />j <br />---- <br />20. Focili Ownar oe Operator Certification of rsx ®lilt of hmaiceus macnab co e c b Yhis manifest except es noted in hem 1 S. <br />Prinled'Typed fJa ro r ( S gnat a <br />4r'6 Day Year <br />DO NOT WRITE BELOW THIS LINE. V <br />DTSC 8022A [1/99) White: TSDF SENG5 THIS COPY TO DTSC WITHIN 30 DAYS. <br />EPA 87150--22 Tc: P.0 nix 3000, Sacramento, CA 55812 <br />