Laserfiche WebLink
Form Approved.OMB No.2050-003) <br /> Please pentr or type.(Porm designed for use on elite(112-pitch) .) NO&— <br /> UNIFORM HAZARDOUS 1.Generemr ID Number 2.Page 1 of 3.EffwWcy Response Phone 4.Manifest Trading Number <br /> WASTE MANIFEST CA 9732 1 SOM46W 011387 44 FL <br /> andMalkV CSS 3 Generators (ifd CV m ng�ress) <br /> 039 <br /> 29983623M 1585 West 11th Street 1885 West 11th Street <br /> C*nmWs PFS: Tracy, CA 95376 Tracy, CA 95376 <br /> 6. ransporter I Company Name U.S.EPA ID Number <br /> Stericycle Specialty Waste Solutions Inc MNSM110924 <br /> 7.Transporter 2 Conpany Name U.S.EPA ID Number <br /> cJ s-4e,MS <br /> :If <br /> . ted , LLILON U.S.EPA ID Nnunt <br /> 2895 Newlands Dr. East <br /> Fernley, NY $9408 <br /> FwWs Done: 7755752765 <br /> ga, gb.U.S.DOT DescriptIon(lrdudIng Proper Shipping Nams,Hazard Class,ID Number, 10.Containers 11.Total T12.Unit <br /> HM <br /> and Paddng Group(f any)) No. Type Quantity WLNol. 13.Wash Cotes <br /> o 12811, Waste Toxic solids, organic, n.o.s. 1 CF 901131161 F 3 1 D017 DOM <br /> (Chromium, Selenium), 6.1, PS Il, ERG#154 <br /> 2' Non RCRA hazardous waste, solid (State 4 DF ON37 F 3 1 <br /> Regulated Solid Consumer Products), <br /> 3. <br /> 4. <br /> 14. 'ng Instructions and Additional Information 1.109196(RX Toxic Solids ) 2. 1 (State Regulated Solids) <br /> 15. Tt WWOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consipment are A*and accuraItety above r slapping nom,and aro classified,paclaiged, <br /> marked and labsted/plaiarded,and are in al respects in proper condition for import accordkV to applicabW international and national gore I If export shipment and I am the Primary <br /> Exporter,I certify that She contents of this consipment conform to She terms of the attached EPAAdmowledgment of Consent. <br /> I ce*that the waste mk*Tdzdm statement Identified In 40 CFR 262.27(a)(S I am a or(b)(S I am i <br /> _s RhWyped Nammom Daycar <br /> 5 Loll 15 <br /> F 16.IntemabonaI Shipments ❑Import to U.S. ❑ er"exit Expat from U.S. Pot of <br /> Z Tran for exports onW: Date U.S.: <br /> W 17.TransporterAdmaMedItment of Receipt of Matimals <br /> Transporter 1 'n ear <br /> zk <br /> CL . Kristo er Almanza 18 <br /> Z 2 Na Y <br /> C 79 <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space ❑ GOVE <br /> -; ElResidueResidue [:1Parte R ❑Full Road, <br /> Mandest Reference Number: <br /> 18b.Alternate Faaity(or Generator)tort U.S.EPA ID Number <br /> V <br /> F phone• <br /> 18e.Signature of Aitemate Fadtily(orGeherotor) w Month Day Year <br /> HEALTH r <br /> OPPARTMENT <br /> Z <br /> 2 1S.Hazardous Waste Report Management Method Codes Pe.,codes for t I,and recycling systems) <br /> ii <br /> ® 1. I q ( 2. �� 3. 4. <br /> 20.Designated Facility Owner or Operator.Certification of racdpt of hazardous materials covered by the manliest except as noted in Ion 18a <br /> Nrteffyped Name SigV�(�! natureI I Lam 61L <br /> La.,JAI I )ff' <br /> EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. DE ATED FACILITY TO DESTINATION STATE(IF REQUIRE <br />