COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

Please print or type.(Form designed for use on elite(12-pitch)typewriter) Form Approved.OMB No.2050-00 UNIFORM HAZARDOUS i.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST 209.944-5714.2002 Q 16 6 7 5 4 4 JJ _ S.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) 6ELKORP Ag. 1120 CHARTER WAY P.O. 60X 6X9 STOCKTON,CA STOCKTON,CA 95206 Generators Phone: 209.944-57142002 6.Transporter 1 Caglpany Name U.S,EPA ID Number George W. Lorry,Ino. CARDOM47019 7,Transporter 2 Company Name U.S.EPA ID Number E �e,4 L C.�.-v-a0 3 8,De Fff" g�W ress U.S.EPA ID Number 2730 E.13th St. AZR000515924 YUMA,AZ $5365 Facility's Phone: 928'3"'9 ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12,Unit HM and Packing Group(If any)) No. Type Quantity Wt.Nol. 13.Waste Codes X 1• NON RCRA HAZARDOUS WASTE SOLID(oily absorbent &debris) DM P 352 Z 2. Uj 3. 4. i i 14.Special Handling Instructions and Additional Information ERG171 L19E GLOVES USE VES INVOICE#f (� 7 e N9S 15, GENERATOR'S/OFFEROR'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 cwndiUpn for transport according to applicable Intemallonal 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 EPAAcknowladgment of Consent. I certify that th aste minimization statement Identified in 40 CFR 262.27(a)(If I a a a large quan(Ity generator)or(b).(if I am a small quantity generator)is true. Generators/Off nted/Typed Name SignatLIK V Month Day Year rr o� ` /) 16.InternationifMoments F- ❑Import to U.S. ❑Export from U,S, ort of entryleici Transporter signature(for exports only); Date leaving U.S,: w 17,Transporter Acknowledgment of Receipt of M 'ais 12 Transporter 1 Printed/Typed Name Signature — M th Y Da Y ar O a CT sporter 2 Printed/Typed Name Si re Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space El Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number, 18b.Alternate Facility(or Generator) U.S.EPA ID Number V Facility's Phone, Uj 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z 19.Hazardous Waste Report Management Method Codes_(i,e.,codes for hazardous waste treatment,disposal,and recycling systems) p 20,Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev,3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (i ri':GtJii7c ;