Laserfiche WebLink
Please print or type.(Form designed for use on elite(1x-pitch).typewriter.} .,,.;;:•.. i~ Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZAf7I]0115 1 Generator ID Number' -'1*­ Rpaqt.i of 3: enijr Respbnse Phone' 4:MasiHesi Tearking.Humbor <br /> WASTE MANIFEST C A. 1. 0 0 0 4 2 4 .8 1 7 1 M 62+4-9136 .1 . .017116224 <br /> J J I' <br /> 5.��IVft WV9�"HT LINE'INC. a r ] idPrRMWiME 1 SC: <br /> 500 OLD.DOMINION WAY 601 DARCY PARKWAY <br /> THOMASVILLE NC 27360 LATHROP CA 95330 <br /> Generator's Phone: 3 36 8 2 2 5 7 6 0 <br /> fi.Ts r(er 1 mpapy Name U.S.EPA ID Number <br /> Ha not nvfroMental Sandoes C A DCI 5 3 8 8 6 7 9 4 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Desipge dgi[06 n¢1Sda.Pddress U.S.EPA ID Number <br /> 1830 WEST 17TH STREET <br /> LONG BEACH CA 90813 <br /> Facili s Phone: 800 827-z6729 C A L7 0 2 8 4 P.9' U 1 9 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity .WIN01.. <br /> I.UNI WASTE Flammagg uquilds,n.o.s. D001 551. <br /> Xe 3, PGIII <br /> 2. <br /> 4. <br /> -.- .tPET.R0C1iE14..Po xa4.749-1eg3 <br /> .l. :....3: D <br /> . <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedere that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and fabeledlplacarded,and are in all respects in proper condition for transport according to applicable inteinationaland national govemmental regulations.If export shipment and.I am.the Pr maty <br /> Exporter.I certify that the contents of this consignment conform to the teims of the attaefied EPAAcMowledgment of Consent. <br /> I certify that the waste minimuation statement iderdf lied in 40 CFR 262.27(a)[f I am a targe quantity generator)or(b)(itI am a small quantity generator)is true. <br /> Generator'sdOffemes Printed(Typed Name Signature Month Day Year <br /> J 16, a ationet Sh' Is <br /> F- ❑]mport to U.S. ❑Export from U.S. Pori of entiylkt: <br /> 2 TransporteiQoatu or exports only): Hate leavfng U.S.:.:-.. <br /> LU 17.TranspoderAdmowtedgmmt of Receipt of Materials <br /> Trampo r Printedffyped Name Sig ore Month • Day - Year <br /> y � � � <br /> Q Transporter 2 Prrntedffyped Name e,7 Month ay- Y r <br /> F- <br /> 18.Discrapancy <br /> 1Be.Discrepancy Indication Space ❑ quantity ❑Type ❑Residua ❑Partial.Re ection ❑Ful Refection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) 71<E RFFERENCED WASTE WAS RECEtVED..HANDUB)MMM~POR SUBSFQ,V,-.F` =o <br /> .J DISPOSAL.•n1RF�TMENf OR.Et 15ECT1058Ylk.OVEtTON.INC.OPOA;IFS-nic-r>gC;iLSi: <br /> U .. '. <br /> r. .. _._. Mkfffs'bRAWW TO THEN,BY THE DEPARTMNT OF TOXIC SUhY.FANCE Ct!,MtOL.MCMI, 4h <br /> LL Facility's Phone: WITH T7111 ENVIRONWXrAL PROTECT]%N AG IN ACCORDANCE WMt 31(E PROVUIONS.7: <br /> Lu 18e.Signature of Alternate Facility(or Generator) Yoar. <br /> FF,.[,iF]tAL•AND STATE.REGULATIONS. CROSBY d OVERTON HAS ALL OP I leCF'590 r <br /> a Pl=MUTS.TO ACCEPT THE REFERFNCED WASTE AND ALL MM WASTE HAS BEEN <br /> 2M <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and recycling systems) <br /> 0 3. 14. <br /> 20.Designated Facility Owner or 9peralor.Certification of recelpt of halardous materials covered 6y the manifest except.as noted in Item 18a <br /> Pdntedff ed Name Signature Month. Day Year <br /> VZ <br /> f t� <br /> EPA Form 8700-22(Rd.3-05) rbvious edildins are obsolete. DESIGNATED FACILITYTO GENERATOR <br />