COMPLIANCE INFO_2015 - Laserfiche WebLink

Home Browse Search

00648. 01 h Please print or type. (Form designed for use on elite 02-6tch) tvoewnter 1 6-11834778 APP:Cnalce 1.07DT19.2 Fnrm Ann -vara MAR rur, ?ncnsrno e��R�S ��8�ac eit�°�eh°��f�Ee�l d :^;;I� a; ^eft! •so t+��'^e ae�e atcr IED FACILITY TO DESTINATION STATE (IF REQUIRED) 10357.1791 - - UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3 Emergency Response Phone d. Manifest Tracking Number WASTE MANIFEST CAL 0 0 0 2 8 0 3 9 9 2 (800) 483-3718 O Q O 9 cj 8 F L E 5. Generators Name and Mailing Address Generator's Site Address (it different than mailing address) Tar„et Store T-"828 280 Spreckels Ave Manteca, CA 95338 Generators Phone: 209 823-9932 ATTN: Reverse Lcg`stics Processor 6. Transporter 1 Company Name U.S. EPA ID Number Clean Harbors Environ7ttantal Services Inc M A D 0 3 9 3 2 2 2 5 0 7. Transporter 2 Company Name U.S EPA ID Number 8.Designa a Facility Nage and Site AdL6 s U.S. EPA ID Number 6.ears ,afDOrs �anJose �G� 1021 Berryessa Road C A 7 0 5 9 4 9 4 3 1 0 Sar. Jose, CA 95133 Facility's Phone: (408) 441-0982 ga 9b. U.S. DOT Description (inducting Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total ' 12. Unit 13. Waste Codes No. Type HM and Packing Group (if any)) Quantity WLNoL 'U�!19'-90, bSTEAEROSOLS,2.I,NCNE, UIMITED QUANTITY, 0001 343 0 X OGT-SP:11396 0 0 1 D F 0 0 0 8 0 P Z ZUN1993,WASTE FLAMMABLE UOUIDS, N.O.S.,(AUCYLALCOHOL 0001 343 X E:THOXYLATES, ALCOHOL DENATURED),3,PG II 0 0 1 D F 0 0 0 2 0 P 3UIt3,3139,WASTE OXIDIZING UQUID, N.O.S.,(HYDROGEN D001 14 i X FERGAiDE, SGDiUiv1 PERCARBONATE),5.1,PG II 0 0 1 D F - 0 0 0 5 P 4UN2810,TOX'C UCaUIDS, ORGANIC, N.O.S,(GLYPHOSATE, 343 X PYRETHRIN),6.1,PG II 0 0 1 D F 0 0 0 2 0 P 14. Special Handling Instructions and Additional Information 1. LC 0.90 LP 1x30DP 3. LCCRO 1x5DP 2. LCCRD 1x50P 4. LCCRC 1xSDP W0415J1844776 FLEET 16234 LP#rARGrT-D21 15 GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby dedare 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 intemabonal 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 EPAArknowtedgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. enera[orslOfferors Printed/Typed Name ` igna rMonth ay ear 05 12 08 j ~ 16. In emational Shipments ❑ Import to U.S. Export from U.S. Port of enbylexit: Transporter signature for exports only): Date leaving U.S.: IX 17. Transporter Acknowledgment of Receipt of Materials C Transporter 1 Printed/Typed Name Signature Month Day ear 0 Peter Huang 1 05 112 108 93 - QTransporter 2 PrntedtTyped Name Signature Month Day Year t- 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantityyp ❑ T e ❑Residue ❑Partial Rejection Full Rejection Manifest Reference Number: 18b. Altemate Facility (or Generator) U.S. EPA ID Number J V LL Fadlitys Phone: W 18c. Signature of Alternate Facility (or Generator) Month Day Year Q Z 5, N 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) j SIV 20. Designated`Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pnnted/Typed ame nature Month Day Year e��R�S ��8�ac eit�°�eh°��f�Ee�l d :^;;I� a; ^eft! •so t+��'^e ae�e atcr IED FACILITY TO DESTINATION STATE (IF REQUIRED) 10357.1791 - -