Laserfiche WebLink
yoo��ggl y$ <br /> Please print or t ,(Form desigow for use on elite(12-pileh)typewriter.) SC PPW 10/10/2017 Form Ap Quad,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generalor ID Number 2.Page 1 of 3.Emergency Response Phone 4,Menteat Tracking Nof <br /> WASTE MANIFEST GAL 0 0 0 3 5 9 1 0 2 1 80014$3-3718 01179'1060 FLE <br /> fpr's Nap�g a n ylgil Address eneral s tE Address[if di erent than mailing address) <br /> WW <br /> 2526 W.Washington Street 2526 W Washington Street <br /> Stockton.CA 95203 Stadrton.CA 85203 <br /> Generators Phone:(2091320-3714 ATTNJesse Lewis <br /> 6. rams er icy Name U.S.EPA ID Number <br /> 7.Transporter 2 Compffiy Name U.S.EPA ID Number <br /> B. e"nated Facility Warne and Silo Address U.S.EPA ID Number <br /> 21 e t kernnR adawLLC CAD990975276 <br /> Buttonwilllmlr.CA 93286 <br /> Facility's Phone: (6611762$200 <br /> ga, 9b.U.S.DOT Description(induding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit <br /> HM and Packing Grasp(d any)) No, Type Quantity MMI. 13.Waste Codes <br /> 1 UN1759,CORRIOSIVE SOLIDS,N_O.S.,(ARSENIC,CHROMIUMI 571 <br /> x S.PG III.(BOITOMASH) _ _-- <br /> Z 2. <br /> W <br /> 3, I! <br /> 4. <br /> 14.SftJiarhdAVWs and AddirronetJration n <br /> 15. GENERATOR'S10FFEROR'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, <br /> marked and iabeiedlplacanded,and are in al respects in proper condition for transport according to appficabfe intemadorral 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 EPAAcknowfedgmenl of Consent. <br /> I cantly Ihat the waste minimization statement Identified in 40 CFR 262.27(a)(if I an a large quantity generator)or(b)(if I am a small quantity generator)is true, <br /> I a <br /> no urm Month <br /> ata <br /> rte'- <br /> J i6>InEemelroncl <br /> i" ❑Impart to U.S. LlExportfrom U.S. text: <br /> of en <br /> Transporter signature for ffj2Ls on : Date leavirC U.S.: — v <br /> JX LU 17.Trarisprxler Acknoxdedgment of Receipt of Materiels <br /> a ransporw 1 Pun yped ane lure mom Day Year <br /> o <br /> IL <br /> to 14 Transporter n e a re ay ee <br /> 18.Discrepancy <br /> 1 Be.Discrepancy Indication Space Ej <br /> QuarrM,y El Type ❑Residua ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 1Bb Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> Facili Phone: <br /> W igne4neof tamale ac9ty or eneretor= Month y ear <br /> a <br /> z <br /> 19.Hazardous Wasto Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1 2, <br /> H132 , <br /> 20.Designated Facl ky Owner or Operator:Certification of receipt of hazardous materials clucked by the rnanilesl except as noted in ItemPfi16e <br /> nl ypod Norma nor re o ay Year <br /> �Su a., v 06 <br /> Zia <br /> EPA Form87DO-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.generator is shipping. <br />