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ARCHIVED REPORTS_XR0005829 CASE 1
EnvironmentalHealth
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2900 - Site Mitigation Program
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PR0545951
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ARCHIVED REPORTS_XR0005829 CASE 1
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Last modified
9/24/2020 3:21:27 AM
Creation date
8/6/2020 11:09:33 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
ARCHIVED REPORTS
FileName_PostFix
XR0005829 CASE 1
RECORD_ID
PR0545951
PE
3528
FACILITY_ID
FA0003612
FACILITY_NAME
Yosemite Avenue Arco AmPm
STREET_NUMBER
1711
Direction
E
STREET_NAME
YOSEMITE
STREET_TYPE
Ave
City
Manteca
Zip
95336
CURRENT_STATUS
02
SITE_LOCATION
1711 E Yosemite Ave
P_LOCATION
04
P_DISTRICT
005
QC Status
Approved
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EHD - Public
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,ARDOUS SPECIAL WASTE & ASBESTOS MANIFEST ' <br /> If waste is asbestos waste,complete Sections I,It,ID and IV <br /> IfNOTw'O. <br /> f 4 Q waste Is asbestos waste, <br /> waste,complete only Sections I,If and III 1�I 512250 <br /> �- IN <br /> i�� <br /> -�k <br /> r8 CrAmmy b Generating Location ARM 8TA770H 0OW20 <br /> c Aaoress - - d Address 171.1 Z. YOsdlrt c <br /> BURM PMC* CA 90622-3077 "A"rack CA <br /> e Phone No (925) 299-8891 PAUL SUPPLE f Phone No R/A <br /> If owner of the generating facility differs from the generator,provide <br /> g Owner's Name ARCO PRODUCTS t:OMPA'tre'Y h Owner's Phone No SassoA8 Z{�� <br /> TYPE <br /> I BFI WASTE CODE C A fl y U 5- l Z 5 0 2 =0 5 Containers DM-_METAL DRUM <br /> DP -PLASTIC DRUM <br /> J Description of waste td0N*Fl�1� fin' k Quante B -BAG <br /> Units No TYPE BA -6 MIL PLASTIC BAG <br /> or WRAP <br /> O D 0 Y 0 1 m T -TRUCK <br /> O -OTHER <br /> GENERATOR'S CERTIFICATION 1 hereby certify that the above named rnatenal is not a hazardous waste as defined by 40 CFR Part 261 or UNITS <br /> any applicable state law, has been property described, classified and packaged, and Is in proper condition for transportation according to P -POUNDS <br /> applicable regulations,AND.If the waste is a t=e sidue of a prei lously restricted hazardous waste subject to the Land Disposal Y -YARDS <br /> Restrictions,I certify and warrant that the waste has n trA�inrdanceyvitttthe requirements of 40 CFR Part 268 and is no longer a M' -CUBIC METERS <br /> hazardous waste as defined by 40 CFR Part 261 hUert of ARM >P'RMUCTS UC>tt'TPANY Y' -CUBIC YARDS <br /> O -OTHER <br /> PATRICIADILLARD/ DILLARD l3NV r +, FF r I•/I -A - <br /> Generator Authorized Agent Name- Signatuie' _ Shipment Date - - <br /> - <br /> TRANSPORTERI TRANSPORTERII <br /> a. Name ' f- " `l f h Name <br /> b Address - L i Address <br /> c. Driver Name/TlUe = -� j Driver Namefri le <br /> RI <br /> PNT/rYPE PRiNT/rYPE <br /> d Phone No _e-Truck No i?F- _k_Phone No - I Truck No -, <br /> f Vehicle License NoJState _ 4r" - '' ?_ -2'7 1 m Vehicle License No/State <br /> Acknowledgement of Receipt of Matenals Acknowledgement of Receipt of Materials <br /> ori e► Date Ddm s re gate <br /> CST(614 O rN4 <br /> c Phone No <br /> a. Site Name <br /> 13FI -- VASCO RWJD SANITARY LANDT'ILL (925) 44'*-0491 <br /> 4001. N. VASCO ROAD- 4001 t1. VASCU ROAD <br /> b Physics!Address d Mailing Address <br /> L3VI;1t PE. CA 945V LIVF.RMD?Trf C7. 94550 <br /> e Discrepancy Indication Space <br /> I hereby certify that the above named material has been accepted and to the best of my knowledge the foregoing is true and accurate <br /> joar 1Cti17 '177 <br /> f Uq--M9tt <br /> Name a Aut►grized Agent Signature Receipt nate <br /> Se 40m§ 'x y ���, �+�.��.te Y.,..� •..: �=' 't :"t ",' r ,Shipper- <br /> * <br /> shipper-completes e);w` �' Fx <br /> a Shippers's*Name b Shippers's* Phone No <br /> c Shippers's*Address <br /> d Shippers's Special Handling Instructions and additional information <br /> CERTIFICATION I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, packag <br /> marked,and labeledlplacarded and are in all respects in proper condition for transport according to applicable international and national governmental regulations <br />
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