Laserfiche WebLink
Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No. 2050.0039 <br /> UNIFORM H42ARDOUS 1 • Generator ID Number 2, Page 1 of 3. Emergency Response Phone 4 Manifest Tracking Number <br /> WASTE MANIFEST L I J S , t` 11 <br /> 5. Generators Name and Mailing Address Generator's Site Address ('d different than mailing address) <br /> 1 i ,'`, a i ' ; :' o J7,�( JL f4 TOWING INC <br /> 1M3o 4`10UTH IDEAL PARKWAY <br /> 4AN " 011 CA <br /> Generator's Phone: "Or Ala 1107 <br /> B. Transporter 1 Company Name U .S. EPA ID Number <br /> P kR 7 ; 0 F <br /> 7 . Transporter 2 Company Name U .S. EPA ID Number <br /> 6.110W. DW10F R[ 4'4r4i~R'Y SYSTEM WC , r. fi, R e) 9 C 1 15 4 2 <br /> 8. Designated Facility Name and Site Address U.S. EPA ID Number <br /> ti ,,t fitoiJ'dt�C, viv;dii �i ( <br /> flr(t) US HIGHWAY 95 <br /> WAA% f'• � 'Sr' a <br /> AZtRr '► 0052114 ( 1 <br /> Facility's Phone: fii' ':'. 17111? 0 f <br /> ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11 . Total 12. Unit 13. Waste Codes <br /> HM and Packing Group (if any)) N( Quantity Wt.IVol, <br /> 1 ' ; 10WIF'CRA WARMIUS W/trTt , soups, ilott tt l+00C>•'r) i <br /> 0 <br /> z 2 , t <br /> LU <br /> ± <br /> 3, <br /> 4, <br /> 14, Special Handling Instructions and Additional Information <br /> " MEW, xENCY CONTACT C 14FMTRFC 1 ,9- r 3.424 • it.S00 }NOE"I TEPMINAI . , CrRF`J CS NAFF k'vA# 9P1 273 * f"ROP4J E N 981 <br /> 11LE3914626 MRS OILY SX1I Uri * * APPR0PPIA7E PPF F0LIJPMFNT <br /> 15, GENERATOR'SIOFFEROR'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, <br /> marked and labeledlplacardeii,, and are In all respects in proper condition for transport according to applicable International and national governmental regulations. If export shipment and I am the Primary <br /> Exporter, I certify that the oonfents of this consignment ooniorm to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(x) (if I am a large quantity generator) or (b) (rf l am a small quantity generator) is true. <br /> Generator's/Offeror's Printedrryped Name Signature Month Day Year <br /> 16. International Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entrylexit: <br /> TransPoter signature (for exports only): Date leaving U .S.: <br /> W 17. TransporterAclmowledgmentofReceipt ofMaterials <br /> a Transporter 1 PrintedrTyped Name Signature Month Day Year <br /> O <br /> a <br /> z Transporter 2 Printed/Typed Name Signature Month Day Year <br /> i f- <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue1e J <br /> ❑ Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> C 18b, Alternate Facility (or Generator) U.S. EPA ID Number <br /> J <br /> V <br /> rat Facility's Phone: <br /> W ' 180. Signature of Alternate Facility (or Generator) Month Day Year <br /> Q <br /> Z <br /> y19. Hazardous Waste Report Management Method Codes (i.e. , codes for hazardous waste treatment, disposal, and recycling systems) <br /> 0 1 , 2. 3, 41 <br /> 20, Designated Facility Noner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pdntedrryped Name Signature Month ay ear <br /> EPA Form 87001,22 (Rev. 3.05) Previous editions are obsolete. GENERATOR' S INITIAL COPY <br />