COMPLIANCE INFO_2020 - Laserfiche WebLink

Home Browse Search

1111111 111 111 1 , 16111 1 1 ■ 1i f11 ■ 111 ■ i ® cvuNF*�L Route : 0A j AND - ROU7.E 1 Fq0# : % 99N - � � `�`�. ' ; C. RI,A?fCl Farm Apve . No. 050-0039 Please print or type. UNIFORM HAZARDOUS 1 • Generator ID Number 2, Page 1 of 3. Emergency Response Phone A. Manliest Tracking Number WASTE MANIFEST CALp (3c) 1AOSp L4 q 006303151 GBF 5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) ,ALIFORM IA AUTOS PO Z l 'L80 BUTTION AVE iP.NTEOA , GA 95 3 Goneralors Phone: ti c '+ r r „ t 6. Transporter 1 Company Name U,S E A1D Number — " -fERITAGEE G.mRY` STAL CLEAN , ?_ tiC I L R 0 O 0 1 3 C `5 2 7. Transporter 2 Company Name U.S. EPA ID Number NO M/ 8, Designated Facility Name and Site Address U.S. EPA ID Number 7ERITAGE — DRYS T AL GLEAN r LLC I L R 0 O 0 13 0 O 6 2 1A50 HOLLYWOOD AVENUE - HREVEPORT , LA 71IC19 Facility's Phone: 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, i ON— DOT/ RC;=:n i alCZU AIEDr ( :4 r;+ UEr�` U= _T' 1;.=: 0 0 ., % 1 ) Z 2. w 3. a . 14 , Special Handling Instructions and Additional Information 1 ) CC &040952191 - 1050 TOD : IJ - 58 FLI ;Is contract retained by generator corners agency aulticsrtV ors. IrdII.; I tr n3pariar !o add or Sumillr 119 addams, 1tfin oftaf3 on gantSraivs banon, 15. GENERATOR'SfOFFEROR'S CERTIFICATION : I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable intemali I 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 EPAAcknowledgment ofn nl. I certify that I e wa le minimization statement identified in 40 CFR 262,27(a) (if I am a large quantity generato r (b) if I a small quantity generator) Is true. e rators/Offerors r 1�d p Na r !I ?711\1?7re Month Day Year I , � 16. International Shipmen s 11 Import to U,S . ❑ Export from U.S. P t of ontrylexit: ? Transporter signature (for exports only): Da a leaving U.S.: Q� 17. TransporterAcknowledgment of Receipt of Materials 2 Transporter 1 Prinledfryped Name \ Signature Month Day Year a .JAN 1 S 23 Z Transporter 2 Prinledfryped Name Signature Month Day Year 14. 1 i 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 U LL Facility's Phone: El 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) cn uro 1 2• 3. 4, 20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Print Eryped Name Signature Month Day Year / S / q EPA Form s7 0.22 (Rd. 12-17) Previous editions are obsolete. ESIGNATED FACILITY TO EPA's enMAAFEST SYSTEM