Laserfiche WebLink
W 19©6258669-002 SC PPW 12/9/200$ Form Approved.OMB No.2a5O-O039 <br /> Please print or". 4.tillfanHest Tracking Number 24 F LE <br /> 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone O 4 <br /> UNIFORM HAZARDOUS {800)483-3718 <br /> WASTE MANIFEST CAL 0 0 0 2 6 3 7 9 4 <br /> Gerrerarors Site Address(ff different than mailing address) <br /> 5. MID „ � LOGIFS SAME <br /> 200 N Wagner Ave <br /> Stockton. (9 5 215 43$5 U.S.EPA ID Number <br /> Generators Phone: MAD 0 3 9 3 2 2 2 5 0 <br /> 6.Transporter 1 Company Name <br /> Clean Harbors Environmerrtaj(Services.lnc. U.S.EPA 1D Number <br /> 7,Transporter 2 Company Name <br /> U.S.EPA ria Number <br /> 8.Designated Facility Name and Site Address 4 H �!` 3.r 3 4 3 1 G` <br /> Clean Harbors San lose LLC <br /> 1021 Senyessa Road <br /> Sart los.eXA 95133 <br /> Facility's Phone: 10.Containers Q Total 12.Unit 13.Waste Codes <br /> 98 9b,U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, No Type Quantity Wt.Nd. <br /> HM and Packing Group(if any}) ?002 791 <br /> 1 UN2796,WASTE SULFURIC ACID.S.PG 11 <br /> x <br /> D002 122 <br /> 2. IN jg24.WA.�,nn1LlM HYDR4xIDE S4]LUTION,S.PG II I P Z 2 <br /> c� <br /> x <br /> 3. <br /> 4, <br /> 14,S t' Iii In tructionsand Add� 151n <br /> t3 s21 <br /> 2_CN1940329 ERG#154 Ct1tf3LtE fined t aenefatix C [eters pen <br /> ro r shipping name,and are classrfied,packaged, <br /> iltilorilty on ETllti3j tiarci;prprtEf to arTd Gf bUDStitUtE 3t3�1ttt7Cf3i tfano thistcofnsignment�are�yand carately descnbed above by the p�ft��4fi E C c�fl,; C <br /> 15. GENERATOR'SlOFFEROR'5 CERTIFICATION: Thereby deciare thaiBre contents <br /> pe proper condition for transport according to applicable intemationatand national governmental regulations.4f export shipment and I am the Primary <br /> marked and labetedlplacarded,and are in all respects in rope rent of Bonar Consent.that the contents of this consignment conform to the terms ofd"am large quantity g hed dqm or(b)on en a small quan4ty generator}is hue. Year <br /> Exporter,I certify 9 Month Day <br /> I certify that the waste minimization statement idenlfied in 40 CFR 262.27(a)( Signature 'Z Q <br /> Gerteratorslofferors PrintedlTYped Name <br /> + 111F1 I f W[h <br /> 1111121,2 ❑Export from U.S. Port of entrylexit'. <br /> 16.International Shipments Lj Import to U.S. Date leaving U.S.: <br /> ZTransporter signature(for exports only)'. <br /> LZ 17 Transporter Acknowledgment of Receipt of Materials Signature 1 7240 <br /> aTransporter 1 Printed/Typed Name L Month pay Year <br /> CL <br /> Signature <br /> Z Transporter 2 Printedf typed Name <br /> 18.Discrepancy ❑Residue ❑Partial Rejection <br /> ❑Full Rep=n <br /> 18a.Discrepancy Indication Space Quantity Type <br /> X. <br /> Manifest Reference Number <br /> U.S.EPA 1D Number <br /> 18b.Alternate Facility(or Generator) ' <br /> Month Day Year <br /> U <br /> Lit. Facility's Phone: <br /> 0 18c.Signature of Alternate Facility(or Generator) <br /> a <br /> and recycling systems <br /> y 19 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal, <br /> 4. <br /> 2. <br /> G 1 H070H070 <br /> the manifest ex as nded in Item 18a Month pay Y <br /> 20.Designated Facility Owner or operator:Certification of receipt of hazardous materials covered by Signatu <br /> printed <br /> FAGiLI PA's e-MANIFEST SYSTEM <br /> EPA Form 87f}0.22(Rev.12-17) Previous editions are obsolete. <br /> Glean Harbors has the aPPr0nate Dernlrts for and will atl:eept the waste the;venerator is s tARtn¢ <br />