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CO0055250
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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2500 – Emergency Response Program
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CO0055250
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Entry Properties
Last modified
3/7/2023 3:32:19 PM
Creation date
3/7/2023 3:30:10 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2500 – Emergency Response Program
RECORD_ID
CO0055250
PE
2546
STREET_NUMBER
6301
Direction
W
STREET_NAME
BANNER
STREET_TYPE
ST
City
LODI
Zip
95242
APN
05532052
ENTERED_DATE
9/23/2022 12:00:00 AM
SITE_LOCATION
6301 W BANNER RD
RECEIVED_DATE
9/23/2022 12:00:00 AM
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
Scanner
SJGOV\bmascaro
Tags
EHD - Public
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Form Aoproved. OMB No, 2050-0039 GENERATOR - UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number <br />C Ar p-,0-- 1 CA -1 I CA <br />2. Page 1 of <br />1 <br />3. Emergency Response Phone <br />e'00 - 5-6tio - c\ock 0 <br />4. Manifest Tracking Number <br />02 2 2 2 8 5 2 8 JJK <br />5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) <br />Uhek (::C7 c' f-,_‘ e: 2 -1-6z-4.4e...v-b.-- (97,e, I w • -&-,,--( 10e- 42- Cit-- <br />ctn.° Joe. v-Vro6e1-4- 7--Nz. CA\ 'IS-24 2- <br />GeUgk5ET.ct--' . -1-K <br /> <br />ii I -II 3- -1b 2-\2-t S I <br />6 Transporter 1 Company Name U.S. EPA ID Number <br />I e-tn,-,c. 41 i50 7'171 OP cS <br />TiAnsporter 2 Company Nape U.S. EPA ID Number <br />CiVOS 47, C)V 4-,1/40 VA i L44 C- I <br />Designated Facility.bme and Site Address U.S. EPA ID Number <br />"I eit 011c,-Y2--: c.,.*-4. C.arzne... „T <br />1(0 lA) 1-7 -t-'4 c•-e-,er.,r- <br />C--PAI--)07-t,L4 0 `I Fat-cili?rs3P(ene:1E-44-)14 `--13-2_- .S- 4 +s-- I 061 t <br />ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID <br />1 <br /> Number, 10. Containers 11. Total 12. Unit 13. Waste Codes Hm and Packing Group (if any)) No. Type Quantity Wt.Nol. <br />1. 0 <br />- ?LS? i\ A-1,17 „, fz..ov,,c li.)A5r-E, Ot...- .1 <br />2_ bv14 g-170 P <br />2. <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information 00 tT • MOL, 2.:& • <br />Ov'61- <br /> <br />`•11-C.,. 'T-- Sa, Ar '2:1 `a t 1 <br />t %'142-C- '-1k CF-x.-Si ) 'T I 1 62-2-10tcr <br />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, aid are classified, packaged, <br />marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable Intemationaland national governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment 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) (if I am a large quantity generator) or (b) Of I am a small quantity generator) Is true. <br />Generator's/Offerors Printed/Typed Name oik _../ X•e-r-4,11._F- Signature Month Day Year <br />JLe----;_r 1-3,...t ---- I 9 IoIz2. 't.) 4e=f4;20..4.7-0$. cr-r-.AC-31-1.• r Co - <br />f-- <br />16. International Shipments LI Import to U.S. Export from U.S. Port of entry/exit: <br />Transporter signature (for exports only): Date leaving U.S.: <br />FN 17. Transporter Acknowledgment of Receipt of Materials TRANSPORT! Transporter 1 Pnnted/Typed Name Signature Month Day Year <br />3011n../ g I I 1 I 3C) I 2:). <br />Trans rier Printed/Typed Name ligriarre Month Day Year <br />idio I/Y-4I 2L DESIGNATED FACILITY 18. Discrepancy <br />Discrepancy Indication Space III Quantity Type LI Residue Partial Rejection Full Rejection <br />Manifest Reference Number: <br />Alternate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone: I <br />18c Signature of Alternate Facility (or Generator) Month Day Year <br />I I <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />. <br />Il <br />1 <br />/iii <br />2. 3. 4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18a <br />Printed/Typed Name Signature Month Day Year <br />.....------ I 4 Irr) I_ 2-.. I) 0 I /O 17--Z- <br />EPA Form 870 <br /> (Rev. 12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM
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