Laserfiche WebLink
SSL SK SHIP# 229117213 <br /> Please print or type. gg (�aa <br /> UNIFORM HAZARDOUS I Generator to Number D 8 7 Fom�Approved.DM�No.2050-0039 <br /> CAR1D00055301 2 Pagel of 3. me�gncy Res�orise Phong 4.Manifest Tracking Number <br /> WASTE MANIFEST f30i6 4b8-17b® 0 0 71816 5 4 SKS <br /> 5.Generators Name and Mailing Address <br /> Tracy Honda G...... re Site Address(i1 different then mai8ng address) <br /> 3450 Auto Plaza Pkwy <br /> TRACY CA 95376-0000 <br /> Generetor'e Phone: 805-830-3642 <br /> 6.T6 TY SL�E£N SYSTEMS INC <br /> U.S.EPA ID Number <br /> 7,T anepoLe 2 Comoaw Name <br /> TXROOOO61205 <br /> �� U.S.EPgIDNumbar-- <br /> 0.Designated Facility Name and Site Address {�PAIO03 1 ZZ� <br /> THERMO FLUIDS INC U.S,ENumber <br /> 12533 SE CARPENTER DR <br /> 503-788-4616 CLACKAMAS a OR 97015-8986 <br /> Faclll 's Phone: OR0000025197 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,10 Number, <br /> HM and Pecking Group(If any)) to.Containers it.Total 12.Unit <br /> No.� <br /> NON—RCRA HAZARDOUS WASTE SOLID Type Quantity Wt.IVof. 13.Waste Codes 1' <br /> (DRAINED/UNDRAINED USED 61L FILTERS) DM P 223 <br /> i 2. Z, <br /> W <br /> t7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Adtlitianal Information <br /> TSD:TPO 80739639 TR34107+ 201931 GS 4 <br /> 24H EMERGENCY#800-468-1760—CH/SK/TFI—Contract retained b `����� • <br /> n y generator confers agency authori y <br /> 16. GENERATOR'S10FFEROR'S CERTIFICATION:1 herebydeclare thatthe wnlenh of this consignment are fully and accurately described above by the proper shipping name,and areclassified,packaged, <br /> marked and labelediplacarded,and are in ail respects in proper condition for transport according to applicable international and national governmental regulations.IFexpori shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terns of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(i{I a a small quantity generator)is true. <br /> Offerors Pdntedfr edy�Name Signature <br /> G" Month Day Year <br /> 16.Intemau'onal Shipments .� <br /> F ❑Import to U.S. ❑Export from U.S. o of on exit <br /> ? <br /> Transporter signature(for exports only): <br /> W <br /> 17.Tre reporter Adirowledgment of Receipt of Materials Date leaving U.S.: <br /> 1 PrtntedlTyped Na gnature <br /> y 11 /� Month Day Year <br /> rier2P' Name �f S <br /> (S••– v� �!r�3 J Month Day Year <br /> 18.Discrepancy ! OQ UI <br /> 18a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> 18b,Alternate Fadlity(or Generator) Manifest Reference Number. <br /> 21 U.S.EPA ID Number <br /> U <br /> LL Facility+s Phone: <br /> 18a Signatu e d Hamate Fadlity(orGenerator) <br /> ZMonth Day Year <br /> 2 19.Hazardous Waste Report Management Method Codes(i.e.,codas for hazardous waste treatment,disposal,and recycling systems) <br /> W 1 3 <br /> 1 2' . 4. <br /> 26.Designated Faulty Owner or Operator:Certification of receipt of hazardous materials covered by the anilest exce s nate ' mi <br /> Printedfryped lure <br /> �— Day Y <br /> EPA Form 870Q22((Rev.f Previous edl ns are obsolete. <br /> 156 ESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br /> f)7872676/ 0�3 <br />