Laserfiche WebLink
t �551 D T S:dk. ��#i�� �� . � . 1{ IIIII110111111111111111111INIII <br /> , " <br /> 0098634768 KS <br /> Please print or type. (Form designed for use on elite (12•pitch) typewriter.) . Form Approved. OMB No. 2050039 <br /> UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. m R s se '' 0 4. Manifest Tracking Number <br /> WASTE MANIFEST CAL000218409 1 - -g 005863476 SKS <br /> 5. Generator's Name and Mailing Address Generator's Site Address Of different than mailing address) <br /> Stockton Sailing Club <br /> 4980 Buckley Cave Way <br /> STOCKTON CA 95219--2025 <br /> Generators Phone: 999•-999^9999 <br /> B. TS r MMM''M SYSTEMS , INCe U.S. EPA IDNumber TXROMOO81205 <br /> 7. Transporter 2 Company Name U.S. EPA ID N be41A I r ^ <br /> ql <br /> 8. Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE U. . EPA toNumber <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE , CA 95133 <br /> CAD059494310 <br /> 4tb8-441 -0962 <br /> Fadliys Phone; <br /> ga• 8b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, to Number, 10. Containers 1 t . Total 12: Unit 13, Waste Codas <br /> HM and Packing Group (d any)) No, Type Quantity WtNol. <br /> 1 f3tl NON RCRA HAZARDOUS WASTE SOLIDS Dt4 Q� P 223 <br /> d0 q ( OILY DEBRIS ) , f47/ eb . <br /> W 2 <br /> 3. <br /> 4, <br /> 14, Special Handling Instructions and Additional Information TSD s SJ ST37222 'n�� ((C//SS]G : <br /> 24 HR EMERGENCY i) 1 -800-468- 1760 ( SK / TFI ) I166W `-�1 'T <br /> AUTH AS " AGENT—FOR " BY GEN TO RETAIN LICENSED SUB CARRIERS AS NECESSARY <br /> 15. GENERATOR'SIOFFEROR'S CER71FICAnON: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, ard are classified, packaged, <br /> marked and labeled/placarded, and are in all respects in proper condition for transport aging lo applicable intematIonal and national governmental regulations. If export shipment and I am the Primary <br /> Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknovdedgment of Consent. <br /> I certify that the waste minimization statement Identified in 40 CFR 282.27(a) (d I am a large quantity generator) or @) ( am a small quantity generator) Is We, <br /> GaneratoWoffopes NameM <br /> Signature M� �? /Year <br /> 7 <br /> 1 08 <br /> .,r 18.. totemnaationaalljlShipments s <br /> F— ❑ Import to U.S. ❑ Export from U.S. Part of entry/exit: <br /> Z Transporter signature (for exports only): Date leaving U.S.: <br /> 17. TranspoderAcknowledgmenl of Receipt of Materials <br /> KT p der 1 PrIntedrIllyped Name SignatuK Month Day Year <br /> OJ4 bib VVI e. <br /> Transports Pri to Name Signature Month Day Ye <br /> yar <br /> 4. . t� <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection <br /> � ❑ Full Rejection <br /> Manifest Reference Number, <br /> 18b, Alternate Facility (or Generator) U.S. EPA to Number <br /> V <br /> rat. Fedliys Phone: <br /> w lkSignature ofAtematoFacility (orGenemlor) Mono Day Year <br /> a <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. 4. <br /> VW ' <br /> 20. Designated Facility Owner or Operator. Certification of ipt of hazardous materials covered by the manifest ex 1 as noted inItem 18a <br /> Print e ^ Signature T M �ay, ye� <br /> C� r <br /> EPA Fo 8700.22 (R v. 3-05) Previous editions are obsolete. D IGNATED FACILITYTq DESTINA 1 TATE (IF REQUIRED) <br /> 1 ) l 1305167 732537 12531 . 1945 <br />