Laserfiche WebLink
'SISIP 2415032474 <br />�la�co nrin# nr fano <br />Farm ADDrovod. OMB No, 2050.0039 <br />o '� I.7� r v'LS edltB& are obsolete.' <br />,7 <br />/DESIGNATED FAGILITYTO GENERAJOR <br />UNIFORM+HAZARDOUS <br />1 • Gend`ralor ID Number <br />f <br />2, Page 1 of 3. Emergency Response Phone <br />Manifest Tracking Number <br />SK5 <br />WASTE MANIFEST <br />0 X82120 <br />1 1-000-4619-1760 <br />5. Generator's Name and Mailing Address Goneratoes Site Address (if different than mailing address) <br />City 01 511:ock-il belt-� Water Freoitment Plant <br />14 #__%jer 1,73a£:r"r.4ti0op'to <br />LOU CA 95242-9545 <br />`+ <br />Generator's Phone:.. 209--937--8906 <br />6.. Transporter 7.Company Name " U.S. EPA ID Number <br />1" T Y-- LEEN SYSTEMS EMS NC T XRG0 Dx21b5 <br />7. Tfarsporler 2 Company Name U.S. EPA ID Number <br />CILE'M HARBORS ENV SERVICES INC 1'#x.903 2-22 <br />U.S. €fA ID Number <br />CLEANR R S SAN JOE. <br />.1.021 BERMESSA ROAD <br />O de JOSE en g51,33 <br />h-�. 8--44 ---09152 Opp <br />Facility's Phone: <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, 10 Number, <br />10, cenfainers <br />11. Total <br />12. Unit <br />13. Waste.Cpdes <br />No.. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />wUVDl. <br />0 <br />1-- CR HA17A�DO US WASTE" 601_IDS, (oil.. <br />� <br />IDS <br />P <br />Y 1�i-ERI) <br />100 <br />Z <br />2. <br />na <br />3 <br />4. <br />.14. Special Handling Instructions and Additional Information <br />24H F tg`, t 2800` tl i o-� `` g: ' 36311 pia :�g4q° c ?L g P cya Ld r Confers+ i OnC gta,,�.Gy'��,h0fj.0 <br />'s <br />�pERGE transporter <br />il�`3-�.r,�. �v..�_s _ 4 �a' s�'a. $?�'t5� add 'i3 �'� a A .�, R' i?' 46.9F.7:�. E€.3.. 4 A. 4 �� opera ?..X�r89`Y�fll f. <br />16. GENERATORS10FFEROWS CERTIFICATION: I hereby declare that the contents of this consignmeht are fully and accurately described above by the proper shlpping name, aril are. classified; packaged, <br />marked and labotedlplacarded, and are in all respects in proper condition for transport according to applicable inlernaliona€ and national governmentalfegulations. If export shipment and I am the Primary_ <br />Exporter, I certify that the contents of this consignmcnt conform to the terms of the atlached.EPAAcknowledgment of Consent. <br />I certifythat the waste minimlzatlon statement Identified In 40 CFR 262.27(a) (if 1 am a large quantity generator) or (b) (if l am a small quantity generator) is trues. <br />Gen_ srat6eslOfferoes PrintodlTyped Name Signature Month Day Year <br />fie 0& �E_ 1/1 12 <br />r <br />16, Internatana Shipments F <br />❑ [mport to U.S. ❑ Expoff from U.S. Part of entryfaxit: <br />Transporter signature (fofexports only): Date leaving U.S.: <br />w <br />LU <br />17. Transporter Acknowledgment of Rocoipt of Materials <br />Transporter 1 Printedl Name Signature Month Day Year <br />Trans orfi ntedlTyped Name Signature r "'' Month Day Year <br />Y <br />18. Discrepancy _ <br />18a. Discrepancy Indication Space <br />❑ Quantity ❑Type ❑Residua ❑Partial Rejection ❑Full Rejection <br />Manifest Reference Number: <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />[:a <br />LL <br />Facility's Phone: <br />460. Signature of Alternate Facility (or Generator) <br />Month Day Year <br />19, Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposall and recycling systems) <br />LU <br />.1. � <br />2. 3. <br />4. <br />20. Cosignale 1=acllily Owner or Operator: Ceriltication of raceipt of hazardous matofials covered by Ute n lfesf aXce0t as lntfad ffiqffgAdl"— <br />PrintadlTyy6ppeed NarpeSignatu f Month Day Year <br />„3Tl•' »�-,mss.- g.! ,sy <br />o '� I.7� r v'LS edltB& are obsolete.' <br />,7 <br />/DESIGNATED FAGILITYTO GENERAJOR <br />