Laserfiche WebLink
Please print or type, Form Approved.OMB No.2050.6039 <br /> UNIFORM HAZARDOUS 1•GeneratoriD Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest ma ing umber <br /> WASTE MANIFEST C 0 6 001798725 1!�/ <br /> ES <br /> 5,Generators Name and Mailing Address YU LISSA GALVAN Genamtoen Site Address(If dtferent than mailing address) <br /> D EK GROUND SAME <br /> 5655 HOOD WAY <br /> TRACY, CA 95377-7717 <br /> Generators Phone: 1200 <br /> 6.Transporter 1 Company Name U.S.EPA 10 Number <br /> GLIA ES TECHNICAL SOLUTIONS IN J D8 <br /> 7,Transporter 2 Company Nemo U.S.EPAID Number <br /> 8.Designated Facility Name and She Address U.S.EPA ID Number <br /> VEOLIA ES TECHNICAL SOLUTIONS, <br /> L.L.C. <br /> 1175 HENSLEY STREET <br /> FacllitysPhone: RICHMOND,CA 94$01 C A T 0 8 0 0 1 4 0 9 <br /> 98, 9b,U.S,DOT Description(including Proper Shipping Name,Hazard Class,0 Number, 10,Containrvs 11.Total 12.Unit 13,Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WINaI, <br /> a X , UN1070,WASTE NITROUS OXIDE, 27 (5.1) G 1)001 <br /> 0 <br /> 1 4 14 is 141 <br /> z.g OWN-RCBA fiAZAEtDOUS WASTE SOLID, (NON-PCB 357 <br /> 1 D F 76 P <br /> 3, <br /> 4. <br /> 14,Special Handling Instnrctiorhs and Additional Information ER Sericite Contracted by VESTS + Contract retained by enerator confers <br /> agency mthwi on initial traasporterto add or substitute aliftonal transporters on generator's beh& -I 1 f ERGA22 7977461 <br /> KMCART07` 2)W:77016 ASLM113849 <br /> 15. GENERATOWSlOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and aocutalely described above by the proper shipping name,and are dassilled,packaged, <br /> marked and fabeledlplacarded,and are in all respects in properco ndition for transport acoording to applicable intematfona€and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this cenalgnrnent conform to the terms of the attadhed ERAAcknowlodgment of Consent. <br /> I certify that thewaste minimlzallon statemenl Idenglred In 40 CFR 26227(a)(d I am a large quantity generator)or(b)(d f am a small quantity generator)Is We. <br /> Generatoes/Olfefoes PAntoNTyped Name Signature Mon Da Year <br /> DC <br /> G <br /> _j 16.Intemai5onal Shipments <br /> ❑Impod to U.S. ❑Export frau U.S. Pat of entrylexil: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Matadals <br /> oTporter 1 Print Name Sign D Yea <br /> tL <br /> Transports 2 PdniedffffM Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indica ion Space ❑ Quantity ❑Type ❑Residue ❑Padlal Refection ❑Fut Rejection <br /> Manifest Reference Number. <br /> I8b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> Lf Facility's Phone: <br /> Q 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> Q <br /> 1 <br /> US 19.Hazardous Waste Repot Management Method Codes(f.a,,codes for hazardous waste treatment,disposal,and"ding systems) <br /> 0 1 /" 2. r[fZ// F— <br /> / <br /> 4. <br /> 20.Designated Facility Owner or Operator:Cartfficallah of receipt of hazardous materials covered by the manifest except as nded in Item 18a <br /> Pnn yped Signature Month Day Year <br /> RET7ZS" <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete, DESIGNATED FACILITY TO EPA'$e-MANIFEST SYSTEM <br />