COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

P16ase print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST C A L 0 0 0 0 4 6 9 4 2 1 909 476-2308 012296351 JJ K 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) Callfornle Water Service Co. California Water Service Co. 1720 N. 1st Street 1602 E.Lafayette St. San Jose CA 95112 Stockton CA 95205 Generators Phone: 4 0 8 3 6 7 - 6.Transporter 1 Company Name U.S.EPA ID Number K-VAC Environmental Services IC A R 0 0 0 1 S 3 0 9 7 7.Transporter 2 Company Name ! U.S.EPA ID Number 6MIK0h st7a/ . U41) C1191 CA116 1395-- 8.Designated Facility Name and Site Address U.S.EPA ID Number USE I Highway 95, 11 miles saUllh of Beatty Beatty NV 89003 N V T 3 3 0 0 1 0 0 0 0 Facllitys Phone: 8W 7gg-394:3 9a. 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. 0 1-Non-RCRA, Hazardous waste,liquid(lab pacid) 331 q DF L© P HI W 2. N a),-{2c.V-f+, }azar do u s Lil oe� DM baa a9 l � i 3. 4. 14.Spada]Handling Instructions and Additional Information t,7r,li0- 5 9b.1)Profile #070131570-20283 W/0 #KN170463, (LU) OfLi- .)0-013Is1o��o3�. Wear proper PPE when handling waste. 24hr Emergency Contact-K-VAC Environmental Services Bill To: K-VAC Environmental 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, marked and labeled/placarded,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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Co ent. I cert) at the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(KIW s all quantity generator)Is true. Genera t eror' P Inted/Typad Na. Signature Mo th Day sal I � (111/ IF J 16.International Shipments I- M Import to U.S. Export from U,S. Port of entry/exit: ? Transporter signature(for exports only): Date leaving U.S.: IX 17.Transporter Acknowledgment of Receipt of Materials 1 Print d Signalure tenth Day Year CL Q rwsporier 2 Prin ama nature Month Day Year 6 11 14- 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 J_ V 11 Facility's Phone: Month Day Year W 18c,Signature of Alternate Fadlity(or Generator) ZZ ca 19.Hazardous Waste Report Management Method Codes(I.e.,codes for hazardous waste treatment,disposal,and recycling systems) C 1. 2. F 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pr n � � . , � Slgnatu Mo th Day Year EPA Form 8700-22-(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED)