Laserfiche WebLink
' DTC- .04641 _ �38 <br /> " r .{c. <br /> SMA <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> ;;Y <br /> UNIFORM HAZARDOUS 1. ncy Generator ID Number 2.Page 1 of 3.EmergeResponle Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CLUt!'111100A AD0.42 017615175 JJ K <br /> 5.Generators Name and Mailing Address j.-' Generator's Site Address(if different than mailing address) <br /> L%*%+dn OM Lala DpwMor'o DTSC ! 89 Fminte"Road and SLmy Road <br /> P.O.Box 806 Stooldon,CA 9521 S <br /> Saommertto,CA 85812 <br /> Generator's Phone: P o <br /> 6.Transporter'1 Company Name .X U.S.EPA ID Number <br /> PARC S aloft Contraotors CAROW159M <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> Staiav,sie SpWaltv Wade Sok km Ino. t0�4 <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> RHO-CHEM,LLC CADW&M4432 <br /> 423 tats AVWAW <br /> tr�svi CA 80301 <br /> Facility's Phone:one:ne: <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 WtNai. <br /> °C X U42811,Toxb Solds,Orgardc,N.O.S.,(htaaat),8.1,PG II 1 OF 10 P <br /> 0 <br /> H. <br /> 2. + <br /> W <br /> to ` <br /> 3. <br /> d. <br /> 14.Speclal Handling Instructions and Additional Information <br /> ERM 164 ERG Book In VaNds.War approMats PPE vlrMrl handing. . <br /> 104) - <br /> J6W388618 CkON2018. 044 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,pac(aged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this con*nment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)Of I am a large quantity generator)or(b)(dl am a pall quantity,generator) <br /> is true..� <br /> GenejatS Offeror'sPrintedrr Name Signature Month Year <br /> -J 16.International Shipments 'U.S. <br /> t. ❑Import to ❑Export from U.S. Port of entry/exit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printedrryped Name Signature Horth Day Y <br /> CL <br /> - � `Vd�-t7, <br /> QTranspyttr 2 Printedrr Name T Sig, tune �' Month Day Yt7ar <br /> QT lU A e <br /> �,6 I Z 1/4' <br /> 18.Discrepancy _ U <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V y - <br /> Facility.Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month DayYear <br /> Q <br /> Z <br /> 19.Hazardous Waste Ru rt Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. 3. 4. <br /> 20.Designed Faclfity Owner o Operator Certipcation of receipt of hazardous materials covered by the manifest except as nded in Item 18a <br /> Prin Ry �e .� / + ��m - ._ Srgnatu�'� � M, nth �Ye <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br /> 13003.2117 <br />