COMPLIANCE INFO_2018 - Laserfiche WebLink

Home Browse Search

Please print or type.(Form designed for use on elite(12-1 typewriter.) - Forfn Approved,OMB No,2050.0039 UNIFORM HAZARDOUS 1.Generator ID Numher - - 2.page 1 of 3,Emergency Response Phone 4.Manifest Track�i+n9 Number WASTE MANIFEST CAD982485351 1 1- 800-466--1760 oQ58D3G'87 $K$ 5.Generator's Name ond.Moling Address Generator's Site Address(If different than mailing address) C;�L-Tranis Shop :L0-•' l_Ut3.i CW5 645 E Pine St. Li CA 95240-3108 Generators Phone: 209"'333,-695,3 - 6.Transporter 1 Company Name - U.S.EPA ID Number SAFETY-•KLEfEN SYSTEMS, INC, T'xR0100f312215 7,Transporter Company Name ' U.S,EPA ID Number- e.Designated Facility Name and Site Address CLEAN HARBORS 9UTTONWILLOW LLC U.S,EPA ID Number. - 2500 LOKERN ROAD t BUTT'ONWILLOW , CA 932106 C'i�11.-'76'x'-Ea200 Facility's Phone: - - (:AD9606'i Sc':'76 ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM , and Packing Group(if any)) 13.Waste Codes No. Type Quantity Wt.A/ol. K r :-�NONE7 NON RCRA HAZARDOUS WASTE SOLIDS, (ABS ,. jry DM , �- ....�. P' 352T. ' �IRI�ENT AND OIL), Ifdd�1," ., ,._.; r ,._ z 2. co a 4. 14.Special Handling Instructions and Additional Information - - T6DaBL. 725491345. CA479,S8 C5G1 f 24 HR NERGENCY 911-800-•4A:r8--L76C1 (3K d TFI) t// l i r ritlrF„ Rr� 6IW Gt -T Thl P Tf -Nr,Fn 51151 RT : .C" ( V'' Zf 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the propershipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.lf export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent I certify that the.waste minimization statement identified in 40 CFR 262,27(a)(If I atria large quantity generator)or(b)(if I am a small quantity generator)is true. Gan fatoeslofferoes Printed/Typed Name '% - - Slgn LureJ /' Month Day Year r V F��'P.A-w* q 16.International Shipments - 1— Ll Import to U.S ❑Expert from U.S. Port of ett'rylexik z Transporter signature(for exports only): - Date leaving U.S.: - - - w 17.TranspotteiAcknowledgment of Receipt of Materials nature SI /'`" o Tra s od'r 1 Printed/Ty7crName - - ry 1 g Month I Da/y Year a Transport 2^Prin d(ryped Name Signature - Month .Day Year S . 17 vz 18.Discrepancy - 18a.Discrepancy Indlcatlon Space ❑- Quaotty [I Type ❑Residue Partial ReJectlon El Full Rejection Manifest Reference Number: 18b,Alternate Facility(or Generator) " - - - _ - - U.S.EPA ID Number - J U ti Facility's Phone: - - Fa 18c.Signature of Alternate Facility(or Generator) Month Day Year Z . y. 19,Hazardous Waste Report Management Method Codes(Io.,codes for hazardous waste treatment,disposal,and recycling systems) O 1. 2. 3. 4, � G1 20.Designated Facility Owner or Operator:Certification n of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/fyped Name Signature Month Day Year lo3lol 117 EPA Form 8700-22(Rev.3-05) Previous editions ay solete: DES11 ATED FACILITY TO GENERATOR 1) '73-70310/407.1:3004