COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

Please print or type. 71 19052514$4 SC.PPW 3`12,'20'19 Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST A R 0 0 0 0 8 9 G 5 6 !8_00;4&2-3-719014216766 FLE 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Quest Industries tic 2515 Boeing Way Stockton.C-$ 20G, Generator's Phone:f 2`'' 14`� 6.Transporter 1 Company Name U.S.EPA ID Number Clean Harbors Environt-nental Services.IMC. 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Clean Harbors Buttonwiliow LLL r w n n �^ n -- r- n —— 2500 West Lokern Road ; uttonwillow.CA 93206 Facility's Phone: 762-6700 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)) 13.Waste Codes No. Type Quantity Wt.Nol. 1 NUN-RC'RA HAZARDOUS WASTE.SOLIDS.(BOROSILICATE � 1G1 FRIT,ZINC'OXIDE) �� CSV y An` 26) i L2 3. I 4. 14.SL anillirDcLlr�strruuctions and Additional Information C1_k t P o5 Contract retalrle�'by generator Confers 30enC ii'v[;t]!Ter tQ aaa or SUOSlI[Ufe addRlOnai 'r3115pQtttsr5 f_7T` gener3tc•r': oenalf fior[s J. u}GS of tr3ns�f}?fattOn P .( _ .H P.rt 'a IP r.-.P nr>; 15. GENERATOR'SIOFFEROR'S CERTIFICATION: 1 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 labelediplacarded,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 EPA Acknowledgment of Consent. I certify that th waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. General ff or' Prnted amt` Signature Month Da Y ar J ISfflirnents � ❑Import to U.S. El Export from U.S. Port of entry/exit: Z Transporte ignature(for exports only): Date leaving U.S.: 17.Transporter Acknowledgment of Receipt of Materials Transpo 1 Printed(iyped me Signa re Month DiV Year �� 1dar nsporter 2 Printed yped Name re Month kay_Z Year F 18.Discrepancy 18a.Discrepancy dication Space uanti ❑R�Refe.n�,W, ❑Partial R 'ecI ❑Full Rejection Off'pC� Quantity S/ty >_ 181b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone C3 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 1. H13P2 20.Designated Facility Owner or Operator:Certification of receipt of hazardous m trials covered by the manifest except as noted in Item 18a —� PrintedlTyp e . { YrL Y Signature ��-- Month Day Year j65LjS61-r,, x- to 16 111 EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM :lean Harbors has the appropriate permits for and will accept the wast he Ienerator is s.lpprn..4.