Laserfiche WebLink
Please print or type. Form Approved.OMB No.2056-0039 <br /> 1.Generator ID Number 2.Page 1 of 3-Emergency Res onse Phone 4.Manifest Trackin number <br /> UNIFORM HAZARDOU5 y p r <br /> WASTE MANIFEST :AI 0331�42" 1 £430 u33 825:' 00 0 7 9 1 w} DAT <br /> 5.Generator's Name and Mailing Address A i TN Kayser F>1'loms.avanh Generator's Site Address(if different than mailing address) <br /> Kelly 1141100M Paint C:omany Kellyy 'e paint C'OMPOrrY <br /> .A7 Cammeraell Sfreel 7i3Z N Tracy 131-+d <br /> Sul Carlos.CA94070 Tracy.CA 95376 <br /> Generator's Phone: 2t'3: j3--494 <br /> 6.Transporter 1 Company Name U.S-EPA ID Number <br /> Inq(miurn (SarrarrlentoX"""ERI PHONE.-CUSt I0#8'7%4)0]4•-'-) CAROW179747 <br /> 7.Transporter 2 Company Name U.S-EPA ID Number <br /> 11 t I Mlpilas k"ERI PHONE-Cult ID#8766-0002"F C.AROOO7.79 747 <br /> S.Des.gnared F;idkity Name and Site Address U-S.EPA ID Number <br /> Ref;: .:3 Tem AfTyde W*CO.SAde CV <br /> Curr t eo +-Jo 2.Wx-Ti'.KM 121 Mx{C;1,,M 1900'1 <br /> Sari Pabi0 Tecate-BC., W4co• CP?15--0 <br /> Facility's Phone: 619-27rtN53 f7hr,,-1•rr,Irec`1417 #CNAERGENC;Y 4&-kI 44-'_L60 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class.ID(dumber, 10.Containers 11-Total 12-Unit <br /> 13,Waste Code= <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 1'NA3W'-), Hamr(ious waste.,I6wr),n u.s (PainI cOcarilf it wittf <br /> X baOufn 3,9. til DOT ERG,#171 <br /> w <br /> 0 <br /> 3, <br /> 4. <br /> 14-Special Handling Instructions and Additional Information D80M SO 143440 <br /> 1;R18-19918 <br /> Pt+maryExponef TL- Inc AOC C:CCES SOLVI-NT 020614 E1 RCI)1 A�]f}f0l1•S Q'D52f1£f Bit SC?Lti]•S 420.530 F.3U <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: 1 hereby declare that die conlenta of this consignment are fully and accurately described above by the proper shipping name,arra are dass{fied,packaged• <br /> marked and labeledlplacarded,and are in all respects In proper condition for transport according to applicable international and rnatiuml governmental.regulal"s.if expnri shipment and I am the Primary <br /> Exporter,I certify,that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent- <br /> certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(Of am a small 4uanUty,generalor)is p u- <br /> GeneratyslOfferor's Printsday Na e(' Signatur4 ` - Month Day Year <br /> �� I.i �{, 'r G F i.I� 1 �'Y�rC bn {1�� r�kl�.F.�YS•�•.-.IY �a �L - �`�� L-� { �•7 � � <br /> _j 16.IntemalJortal Shipments <br /> F ❑import to u-s. ®Export from U-S Port of en4 lexit. <br /> Transporter signature(for exports only), Date leaving U.S.. <br /> 0� t7•Transporter Acknowledgment of Receipt of Materials <br /> w <br /> Transporter 1 Printed/Typed Name Signature Month Day Year <br /> Crd <br /> Q. <br /> z Transporter 2 Printedayped Name Signature Month Day Year <br /> 1 a.Discrepancy <br /> 1 Ba,Discrepancy Indication Space ❑ Ouanwy ❑Typej <br /> ❑Residue ❑Partial Rejection ❑Full RejecGon <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U-S.EPA ID Number <br /> ci <br /> LL Facility's Phone: <br /> w 18c.Signature of Alternate Facility{or Generator} Month Day - <br /> 4 <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal.and recycling systems) <br /> 1, 2. 3- 4. <br /> 20.Designated Facility Owner or Operator;CerSrrcatlon of receipt of hazardous materials covered by the manifest except as doted In Item 1 B <br /> Printed/Typed Name Signature Month Day <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />