Laserfiche WebLink
Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAM13OU5 1 1 Generator ID Number 2.Page 1 of $-Ep W6Twe Phone 4.Manliest Tracking Humber <br /> WASTE MANIFEST C A L 0 0 0 4 2 4 8 1 7 1 �f{{J]UU 020350666 <br /> n 6 1 11! <br /> 5.b�tT:60KMi�T LINE INC. U �JL1 f� <br /> KINS <br /> 500 OLD DOMINION WAY 601 DARCY PARKWAY <br /> THOMASVILLE NC 27360 LATHROP CA 95330 <br /> Generators Phone: 3 3 6 8 2 2 5 7 6 0 <br /> a <br /> no r rimer7tal Services uL� A�N� 3 8 6 6 ? 9 4 <br /> 7.Transporter 2 Company Name U-S.EPA ID Number <br /> 8.�e�igddress U.S.EPA IU Number <br /> 1630 WEST 17TH STREET <br /> LONG BEACH CA 90813 <br /> FadlitirsPhone! 800 827-6729 1C A D 0 2 8 4 0 9 0 1 9 <br /> ga 9b.U-S-DOT Destriplion(rdud'mg Proper Shippng Name,Hazard Gass,ID Number, 10.Oontainers 11.Tdat 12-Unit 13.Waste Codes <br /> FiM and Packing Group(if any)) No. Type Quant ty WI.NoI. <br /> ' LIQM,65' Till VT Rkl qVeAW►r�t �3�F�*L til ��� �� � � poa� 33� <br /> 2.g�H�' Shti --j IV^Ari{ D 0 1 W q0 <br /> c� <br /> 3-01) [i�WYRc7uG� 1 V1 s Z V <br /> DD I DF <br /> wk\ (La) <br /> 140;0'Y E'E"kc V a'g"rlN"19-00365 1)LP55440-1 PETROCHEM PO# H36 88-19 CA4772, CA4849, <br /> 5AJ14 8 8 0 <br /> 15. GENERATOWSIOFFEROR`S CERTIFICATION:I hereby declare that the contents of Gus oonsigrment are fully and accurately descn77ed above I q the proper shipping name,and are dassiCled,packaged, <br /> marked and labeledlptaa ded,and are in all respects In proper conditlon for transport according to applicable irhtematonaland national gavernme ital regulations.If export shipment and I am the Primary <br /> Exporter,I ou"that the Contents of tNs consignment mnfom to the terms of the atladhed EPA Adknr Medgmenl of Consent. <br /> I Ceftfy that ere waste minimization statement identified in 40 CFR 282.27(a)(ii am a large quantity generator)or(b)(if l am a small quantity gerN ral ks true. <br /> GeneratodslOtferors PrinledlTyped Name Sgnatu Month Day <br /> a Year <br /> ifi.na1 Shi <br /> Import <br /> to U-S. Export horn U.S. Port of entrylint <br /> t Transm r signature efforts only): Date leaving U.S.: <br /> sr 1T-Transporter AcilmowledgmentofReceipt ofMaterials <br /> Transporter 1 Prinledayped Name Sgn& Ih Day Ye <br /> b <br /> rL <br /> az Transporter 2 Pdntedfryped Name Signa Month Day Year <br /> GG <br /> F <br /> 18,Discrepancy <br /> 18a-Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue El Partial Rejection ❑Full Re e:t an <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> ti Facl Ph.: <br /> w ISc.Signature of Attemale Faality(or Generator) Month Day Y r <br /> Q <br /> z <br /> F,, 19.F€azardaus Waste Report Management Method Codes V.e.,codes for hazardous waste t'eatmenl,disposal.and recyding systems) <br /> 0 1- 2. 3- 7- <br /> 20- <br /> Designated Fadlity Owner or Operator.CertJflcakon of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedlTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />