CO0052442 (3) - Laserfiche WebLink

Home Browse Search

Form Anoroved. OMB No. 2050-0039 Please print or type. UNIFORM HAZARDOU q� Generale, ID Number 2. Page 1 01 3. Emergency Response Phone 4. Manifest Tracking Number 020623103 J J K WASTE MANIFEST CAC003082601 5. Generator's Name and Mailing Address Generators Site Address (if different than mailing address) KEHE Distributors LLC 1245 E Diehl Rd Ste 200 Naperville, IL 60563 4650 Newcastle Rd. 630-343-0000 - Stockton, CA 95215 Generators Phone: 6. Transporter 1 Company Name U.S. EPA ID Number Ancon Marino CAD980737068 7. Trpq ter 2 Company Name U.S. PA ID Number ` - � � v :) I �, i Wiz_. L �G i } -�. LLC 8. Designated Facility Name and Site A dress U.S. EPA ID Number Crosby 8t Overton 1630 W. 17th St. - Long Beach, CA 90813 Facility's Phone: 562 432-5445 - 8409019 ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (it any)) Quantity Wt.NoI If ' NA1993, Combustible Liquid, n.o.s., (Water, Diesel), Comb, 343 P P X PGI11 3 DM 150 G W W 2 Non-RCRA Hazardous Waste Solid (Diesel, Debris) 352 2 DM 200 P 3. 4. 14. Special Handling Instructions and Additional Information 1. ERG 128 Bulk Liquid (345g) Profile# 112556 ( 7� 2. ERG 171 Debris (265g) Proille# 99611 ERG Book 1n VNdcie: Wear propel OSHAepproved PPE when handnr>o b -m CES Prolect# EM201146S3 - JWM meterlNs on this nurgilat. Job# 400.13.28523 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, packaged, 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 Exporter, I certify, that the contents of this consignment conform to the terms of the affached 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/Offerors Printedrryped Name >:,,I — 0,A L� {�.-.:7=— Signature-71Month Day Year 9 v l� -j 16. Internationai Shipments ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: F ? Transporter signature (for exports only): Date leaving U.S.: W 17. TransporlerAcknowledgment of Receipt of Materials FW— Ir ,ler 1 Printed/Typed Name S' a Month Day Year _ t r lZ U/� Z Trer 2 Printe yped Na a i ig ature Month Day Year L 1 l ; 18. Discrepancy 18a. Discrepancy Indication Space ❑ quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number. 18b. Alternate Facility (or Generator) U.S. EPA ID Number J U LL LU Facility's Phone: IK 1Signature of Alternate Facility (or Generator) Month Day Year ZZ 0 19. Hazardou Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 1, , 2. �\-i 3. 4. lq ,� 20. Designated aality Owner or Operator: Certification of receipt o hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed N To Signature Month Day Year -e ala Cl V �o -� - EPA Form 9700-22 (Hev. 12-17) Previous editions are obsolete. 1� vearura A r cu F;aklir_i r r 4• r r -r � ,err+,<„ --, —, — , .-.,.