COMPLIANCE INFO_2015 - Laserfiche WebLink

Home Browse Search

Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.E e ncy Res s hone 4.Manifest Tracking Number WASTE MANIFEST Q L ' fib-42IM60 004004635 JJK 5.Generator's Name and Mailing Address Generator's Site Address(d different than mailing address) U. W40 ar //1oj/ 77oi i,4A O',jti,� s t- L 5To&(r G'' G Generators Phone: D Number 6.Tr 9t�99k"9NVIRONMENTAL SERVICES U.S.EPA CAD982413262 7.Transporter 2 Company Name U.S.EPA ID Number 8.DesigWWqdp(rca[d S tltdrfMC U.S.EPA 10 Number. 6880 SMITH AAV�IVLLEN1I�IVVUE NEWARK CA 94560 CAD980887418 Facility's Phone: 510-795-4400 ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 1. NON-RCRA HAZARDOUS WASTE, LIQUID 0 2t z y 001 TT G Z 2. W C7 3. 4. 14.Special Handling Instructions and Additional Informaticn PROFILE # Invoice #}-0909y DOT ERG#171 WEAR PROTECTIVE CLOTHING Sales Order #)/67.2/ 15. GENERATOR'SIOFFEROR'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, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemational 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 EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)it(b)(if I am a small quantity ge rotor)is true. Generators/Cfieroes PrintedlTyped Name Signa Month Day Year regsrY 4nt Z i 03 117 10 16.International Shipments P- ❑Import to U.S. ❑Export from U.S. Pcn of entry/exit: Z Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Matenals cc Transporter 1 P ntedlTyQed Name Signature Month Day Year ti / ( oari� �� 0-7 / 7 0 ZZ Transporter 2 Printe67yped Name Signature Month Day Year H 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number 18b.Alternate Facility(or Generator) U.S.EPA ID Number J_ V Fac titys Phone: C3 18c.Signature of Allemate Facility(or Generator) Month Day Year N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) G 1. -- 2. T 4. 3J 20.Designated Facility Owner or Operator.Certfication of receipt of hazardous materials covered by the manifest except as noted In Item 18a Pnnted(Typed NSig III Month Day Year a�a� EPA Form 8700-22(Rev.3-05) Previous edition re ob late. DESIGNATED F CILITY TO DESTINATION STATE (IF REQUIRED) 10516.0454