Laserfiche WebLink
I Z(701 SC PPW 10/10/2017 <br /> Please 22ni or type.(Form des red for use on elite(12-pitch)typewriter.) 2 L9 6 Form <br /> Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2,Page 1 of 3,Emergency Response Phone 4.Manifest Tracking!lumber <br /> WASTE MANIFEST C A L 0 0 0359102 1 (800)483`371$ 1011791059 F L F <br /> 5. Aft" ddress Generators S ( ntputn martng add <br /> 2526 W.Washington Street ?52a Wit 10-20,i„mn„Qtrant <br /> M •• ii Y+f ffakLVf VMf.F• <br /> Stodeon.CA 95203 Stodrton.CA 95203 <br /> Generators Phone:(2091320-3714 ATTNJesse Lewis <br /> ramspatar U.S.EPA ID Number <br /> Ailljl r CAA00014E3 <br /> 7. ranspofer 2 CompamfNamo U.S.EPA ID Number <br /> 8.Designated FauTiity Name and Site Address U.S.EPA ID Number <br /> Clean Harbors 8uttonwillow LLC <br /> 2500 West Lokem Road CAD 9 6 0 6 7 a 2 7 G <br /> Suttonwillow.CA 93206 <br /> Facility's Phone: (6ja HMO <br /> ga. 9b.U.S.DOT Desrsiptim(including Proper Shipping Nemo,Hazard Class,ID Number, 10.Containers It Total 12.Unit <br /> HM and Pecking Group(rt any)) 13.41 de Codes <br /> No. Type Quantity WWaI. <br /> 1'UNV59,CORROSI VE SOLI DS,NA.S-(ARSENIC.CH ROMIUML 571 <br /> X 8,PG Ill,(90TIFOMASH) b7r" <br /> w 2, <br /> 3. <br /> 4, <br /> , <br /> 14.Special HandIrV Instructions an:17221 orha n maticn <br /> 1.1051346380 E8�#154 <br /> 15, GENERATOR'SKIFFEROR'S CERTIFICATION: 1 hereby declare that the contents of This consignment are fury and accurately described above by the proper shipping name,and are dossilled,packaged, <br /> marked and iaboledlptacerded,and are in all respects in proper condition for hmpcd acounfing to applk;abte inlematlonal and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of fhis conalgnment cordorm to the terms of the attached EPAActrhoM*ment of Consent. <br /> I ce*that the xasie minimization statement identified in 40 CFR 262.27(a)(If 1 am a large quantity generator)or(b)(if I am a small quantity generator)Is hue. <br /> a mo aar <br /> 116.International S"nts _W. <br /> ❑Import to U.S, ❑Export note U.S. Rid of ext: <br /> Transpqw signature for exports.only): Date leaviV U.S.: <br /> Of 17.Transporter Acknowledgment of Receipt of Materials <br /> Trarh6porlor 1 Name ear <br /> Tut <br /> jd <br /> .4 <br /> Transporter 2 Pd Nome re ay Tear <br /> 18,Discrepancy <br /> 18a.Discrepancy indicaffon Space ❑ lluantity ❑Type ❑Residue ❑Partrel Rejeclion ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate facility(or Generator) U.S.EPA ID Number <br /> 7 <br /> U <br /> Fadi s Phone: <br /> 4W 1k ignakue f Alternate Facifdy(or Generator) Month Day Year <br /> z <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous wade treatment,disposal,and racyd'ing systema) <br /> G 1. 2 a: 4. <br /> H132 <br /> 20.Designated Facillly Owner or Operator:Certification of reoelpt of hazardous materials covered by the manifest except as noted in Item 18a <br /> WdintadfTypad Name Signature Lw1b Day Year <br /> 09" 7-1-4RL212 z 1 <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> clean harbors has the appropriate permits for and will accept the waste the Xenerater is shippirf d. <br />