Laserfiche WebLink
Pleasepdnt or tyForm designed for use on elite 12- Itch)typewriter. Form Approved.OMB <br /> pe <br /> �g <br /> st <br /> Traekin Number <br /> r7l <br /> 1� 3. R Prone <br /> 4.Manns ® 4 <br /> 1.Generales <br /> ID Nranl>er Emergency Response <br /> UNIFORM HAZARDOUS 4 JJ <br /> WASTE MANIFEST GpLocB.�sf CST 2f�R 3dt•571�-xx,: � <br /> 5.Gem's Name and Mailing Address Generalors Address{N thanmaifing address) <br /> 1XUtt7aiP,d9. <br /> P.O. Sof 50%5 GTOl;KTr3td.Via' <br /> STMKTON,CA 9220 <br /> Generators Phhme: ]Id.l3g4 T9d SKt� - • ..- ; <br /> 8.Transporter 1 Company Nitre U.S.EPA lD Number = <br /> r;�? �.tAtMTy;anu.. _..,..� ., _ _• _ W!r'`aC±�'ojt''Q1�i <br /> 7.Transporter 2 Company NameU.S.EPA ID Number <br /> NOV 20 2015 <br /> U.S.EPA ID Number <br /> 1S)E. RUMAGE!txf IL <br /> S�►�`�� <br /> ENVIRONMENTAL <br /> tMr tit Wit? HgALTH DEPARTMENT <br /> Fad S PtiOn@ ' <br /> 9b U S.DOT (ndu g Proper Shgpung femme.Hu and Gess,ID Number 10:Contamets.:, 11 Tot 1 f2 Unci •: 13 Waste Codes <br /> HM amid P8drg G Cg"Y)) to. type Quanbly WtN°I. <br /> X t, thSOM RCR. ;K4z-N 0(3B'111%0zlT SCI€$ 1.0 itt;5f#at?t <br /> G ' <br /> w <br /> C9 <br /> .3 <br /> 4. <br /> 14.Special Handling InsUnxdions arndAddi4torna!tttamation <br /> GC�K,`�ili 4hi4`QSCE# �'£?.f7f'fr,�,w <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this.consignmerd ate fully and accurately described above by the proper sNpptng smarms,end are classified,packaged, <br /> marked and IabeledlNacardad,and are in at respects in proper condition for transport according to applicable irdemalio nadand national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certdy that the conterds of this consigrurhert c ontomn to the terms of the attached EPAAcknowledgnent of Consent. <br /> I certify that the waste mirramaellon statement Wended in 40 CFR 282.27(a)(i I am a large quantity generator)or())fit I am a small quantity generator)is true. <br /> Generato roes Printed/Typed NaSr�hai+ae Month Day Year <br /> -J 16.International^�Shipments ❑ Port of eniryfemh <br /> t <br /> Transporsignature(for exports only Import b U.S. Fxpotl tion U.S.: Date leaving U.S.: <br /> a 17.TtansporlerAckhowle0refit of Receipt OfMaWds Month Day Year <br /> a Transporter 1 yped Sgnature ` 1f <br /> c .S` �.. <br /> Z Transputer 2 Printedffyped Nam Signature Month Day Year <br /> 19.Discrepancy._ <br /> 18a.Discrepancy Indication Space Quantity ❑Tye ❑Residue ❑Partial Rejection 1_J Ful Rejection <br /> Manifest Reference Number. <br /> M.Alternate Facility(or GeneratoU.S.EPA ID Number <br /> Generator) U.S. <br /> C? <br /> FadTtys Phare: Month Day Year <br /> UJ 18c.Signature of Alternate Ftp(or Generator) <br /> N19,Hazardous Wast Ff*rt Management Method Codes(ie.,codas for hazardous waste treatmarht,disposal,and recycling systems) <br /> LU 1. <br /> 20.Designated Facility Owner or Op erptor:Certification of receipt of hazardous Mortals covered by the manifest except as noted in E <br /> r I Signature --Month Day <br /> PrI ted7fyped ams <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. TRANSPORTER'S COPY <br />