Laserfiche WebLink
DTSC- 01183. 2227 <br /> Please print or type.(Form des' sed for use on elite 12-pitch)typewriter.) 6126023 1 SC PPW 10/5/2009 Farts Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emergency Response Phone 1"TO040 <br /> beWASTE MANIFEST CAD 9 811®3 9 7 5 2 `800)483.3718 3 M W I <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Stoddon USD Two Yod <br /> 1932 N.ElPinal DirIft SAME <br /> Stockton,CA 96306 <br /> Generators Phone:`209)933-7045 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> CkM H111111lboraEnV1Mnm oalno MAD039322250 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> QMn 1021B �SJ wu Rom CAD06949431.0 <br /> San Jose;CA 95133 <br /> Faalitys Phone: (40811441-0962 <br /> as. 9b.U.S.DOT Description(inducing Proper Shipping Name,Hazard Class,ID Number, 10.Containers . 11.Total 1Z Unit 13.Waste Codes <br /> HM and Packing Grasp(d any)) No. Typo Quantity M fVd. <br /> 1 RQ,UN1950,WASTE AEROSOLS,2.1(0001),(UMITED 004 D F 00740 p � 0001 <br /> x Q 'DOT-SP 113961 <br /> all- <br /> 2•RQ,UN199S,WASTE FLAMMABLELIQUIDS,N.O.S., 213 D001 <br /> LU X (PEMLEUM DI VILLATES),3,PG 11(DOOi) 001 OM 00200 P <br /> 3•IM,UN1263,WASTE PAINT,3,PG II(01001) 001 OM 00130 p 331 0001 <br /> X <br /> 4.NONE NON RORA HAZARDOUS WASTE UQUI ,(LATEX 291 <br /> PAIWI%WA 001 DM 00350 P <br /> 14.Special Handling Instructions and Additional Information ('LEET#5234 <br /> 1.CR405076 ERGg126 3X55,1X30 <br /> 2.CH405069 ERG$128 1x55 <br /> 3.CR405073 ERG#128 1X55 <br /> 4.CH405066 1X55 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of tidy consignment are fdiy and accurately described above by the proper shipping name.and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.0 export shipment and I am the Primary <br /> •Exporter,I certify gnat the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I ceftiry that the waste minimization statement Identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(dl am a small quantity )is Vue. <br /> GeneratorstOftemrs PrntedfTyped Nam Signature Month Day Year <br /> -A�faez� 11 in 109 <br /> Ij 16.International Shipments [Ito U.S. <br /> i ❑Export from U.S. Pat of entryfexit <br /> 2 Transporter signature(for exports only): Date leaving U.S.: <br /> 17.TransporterAcknoaledgme t of Receipt of MaW;als <br /> Transporter 1 Prntedfryped Name Month Day Year <br /> a MARCS 018Lvk- 1i Ila lag <br /> Transporter 2 VdnWffyped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El Quantity ❑Type ❑Residue ❑Partial Rejection ❑Fun Rgection <br /> Manifest Reference Number. <br /> 18b.Ahemate Facility(orGenerator) U.S.EPA ID Number <br /> U <br /> W Facdity's Phone: <br /> W 18c.Signature of Alternate Facility(a Generator) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recydkg systems) <br /> ® 1- H141 2..H141 3' Hi41 4. H141 <br /> 20.Designated Facility Owner or Operate:Certification of receipt of hazardous materials covered by the mernif except as loin Item 18a <br /> P yped N me � Sig Month/^ D Y <br /> r �+� 11 <br /> EPA Form 8700.22(Rev.3.05) Previous editions are obsolete. DESIGNATED FACILITY TO D TI ON STATE(IF REQUIRED) <br /> owepedinpomftforeol0650.2270t EIi 9Dm i&shi ' 8: <br />