COMPLIANCE INFO_2007 - Laserfiche WebLink

Home Browse Search

Please print or type. (Form designed for use on elite (12-pitcr , .ypewriter.) Form Approved. OMB No. 2050-0039 UNIFORM HAZARDOUS t, Generator ID Number age 1 of 3. Emergency Respons a 7anifest Tracking Number WASTE MANIFEST 000971175 F L E 5. Generator's Name and Mailing A ress Generator's Site Address (if different than mailing address) Centra! Valley Waste Systems San JoagOrt Court/ Solid Waste Divii, PO Bax 1810 1333 East Tumer Road Stockton, CA 95201 Lodi., CA 95240 Generator's Phone: 209 4168-3170$ AT7f'J: Kirrrbm A,ndrervs 6. Transporter 1 Company Name U.S. EPA ID Number Clean Harbors Em Services Inc M A D 0 3 9 3 2 2 2 5 0 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number Clean Harbors San Jose LLC: 1021 Elerryessa Road C A D 0 5 9 4 9 4 3 1 0 SanJose, CA, 95133 Facility's Phone: 408 441-09162 ga 91b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit HM and Packing Group (if any)) No. Type Quantity Wt./Vol.13. Waste Codes 1. .... ..._ . 0 , J 2 NON RCRAr HAZARDOUS WASTE LIQUIDS, (LATE( PAINT 817 (HH"), NONE 3. 4. 14. Special Handling Instructions and Additional Information 2. ct12aJB4C1 /✓�!/ 15. GENERATOR'S/OFFEROR'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, packaged, marked and labelad/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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. Generator's/Offeror's PdntedlTyped Name Signature Month stay ear 16. International Shipments ❑ Export from U.S. Port of entry/exit: /exit: El Import to U.S. p ry z Trans orter signature for exports only): Date leaving U.S.: W17. Transporter Acknowledgment of Receipt of Materials I- Transporter 1 Printed/Typed Name Signature Month ayf Year aTransporter 2 Printed/Typed Name Signature Month Day Year H 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity EJType El Residue Partial Rejection Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J U Q LL Facility's Phone:, W 18c. Signature of Alternate Facility (of Generator) Month Day Year Q z 19. Hazardous Waste Report Mainagement Meted bodes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) LLI L _ 2. /` r / 3. 4. 20. Designated FiFjit' 10wwner or Operatol Certification of receipt of hazardous materials covered by the manifest except a noted in Item 18a P' yped,Name/ Signature Month Day Year tim ` W StgibW &WdIffillleand 40 ameot the Waste the generator is shim*al DESI A D FACILITY TO GENERATOR