Laserfiche WebLink
Please print or type. (Form designed for use on elite (12 -pith) typewriter.) <br />Farm Approved. OMB No. 2050.0039 <br />EPA Form 8700-22 (Rev, 3-05) Previous editions are obsolete. DESIGNAI W I AQILJ l T i u uCo i oval tun s to i r tlr tceuluttccut <br />UNIFORM HAZARDOUS <br />1, Generator ID Numb r <br />C A R 0 6 0 2 2 0 7 0 7 <br />2. Page 1 of <br />1 <br />3. Emargency Response Phone <br />(405) 2 42-2643 <br />an st Tracking Number CC <br />007 6 4 7402 I -LG <br />WASTE MANIFEST <br />5, arta s oma and MalllngAddrws Generator's Sia Address (if different than mat Ing a <br />Love's Country Stores of California Lore's Country Stores of California ;x223 <br />P Hoz $092 1552 W- Creon Road <br />-O. <br />Rancho Santa Margarita, CA 92688 Ripon, t3 95�t6fs <br />Gonerator% Phone- <br />6.Transporter 1 Company Name2LU.S. <br />EPAID umber <br />SELSHIREGEIVE[,�CAR0 <br />0 0 18 3 9 13 <br />7. Transporter2 Company Name U.S. EPA ID Number <br />APR <br />8, Designated Facility Name and 8fteAddmii U.3. EPA ID Number <br />U_ S. Ecology Nevada Operations 8 V T 3 3 0 0 1 0 0 0 0 <br />N, 890Q31es S.of Batty rNVIRONMENTAL <br />Beatty, <br />Sreatty, <br />Feet sPhone, (775) 553-222W�-Tf J-701r-Yr!8rV+ <br />9a <br />9b, US. DOT Oeac iption (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Contaimrs <br />11, Tont <br />12. Unit <br />13, Waste Codas <br />No. <br />Typs <br />HM <br />and Padarg Group (ti arry)) <br />Quantity <br />VR./Vol. <br />a <br />Nan--RCRk HA sardous Watate, 3olJ dt (ERG #171) <br />P <br />382 <br />*9918 <br />001 <br />UM <br />zoo <br />z <br />z. <br />W <br />t.? <br />3, <br />4 <br />14.3peclai Handling InstrvOorra and Additional Information 4l�tStia xs exam t #coin FOLDYAK0 <br />SI ' cJ 3 LIME <br />OFt17V <br />Generator is a F R& CESQG under .40 CFR State and radmral Land SIDH OF IV <br />26.1.5. 9010 coda r"remantfs oeaate that 9ispaval Renstriartiottss NA <br />is RCCA. ldmtsfied but nodi RCRJL TTAAB Mit <br />regjtl3itY;etl. FRorILE # 010127389-206 unmiaro6rl;Y <br />16. GENERATOWSIOFFERORIS CMTIFICATIONO heretiy declare tMt the content of this consignment are fully end a ccumtelydwfibod above by the proper shipping name, and are dassi0ed, packaged, <br />marked and Iabaledlplecarded, and are in all re�pe 'n proper conddlon rot transport a000rding to applicable International and national governmental regulations. If export shipment and I am itis Pdit)M <br />Exporter, t certtfy that the cornento of this consignment conform to the Ietma of the attached EPAAcknewledgment M Consent, <br />I cer* that the waste rdlnimlz*fl statement tdentifIN In 40 CFR 262.27(x) (#I am a Ierge quanthy generator) or (b) (K I am a small ganerator) is true, <br />Gffwatot'S1f)IfWr's PrinlodlTyped Name g . re ay Year <br />La.sry iMoothart 01 5r8I on behalf of generator <br />102115 <br />18. IntematiolarShipp�ertts ElImpart fo u.S. tw l Export from U.S Port of entryle dt; <br />.:, <br />'trans orter a ttb re nor on ; Date leavt U'S.: <br />tY <br />17. Transptterftrowledgtiem plotMateHats <br />Transporter 1 Printed(Typed Month Day Year <br />STB V6r4 ' ::: a n'a 0QZA I-0-ij 0Z. Ili <br />,.M <br />Trattsporhtr 2 1`0111017ypod Name Wmnth Day year <br />F <br />1S. Oisctepanry <br />18e, 01saepancyindlottlon Space Quantity ❑ Type ❑ Residue ❑ Partial Re)ectlon ❑ 1=u11 Rei%cAon <br />Mani`est Reference Number: <br />18b. Ahemate FEidlity (or OeneratDr) U.S. EPA ID Number <br />'a <br />Fadi s Phone; <br />W <br />18c, SlgneNre ofAltamata Pxdllty (ar 4enerntor)Month Day ear <br />Y <br />19. Hazardous Wssta Report Management Method Codes (.s., codes for hezarcoue waste treat rant, disposal, and recycling systems) <br />20. Designated Fadllty Owner or 0perstoc Cer(f cation of recelpt of hazardouti materiels covered by ttie manifest except ea noted in Item 189 <br />PflnIedrN*ante Signature Mont Day year <br />EPA Form 8700-22 (Rev, 3-05) Previous editions are obsolete. DESIGNAI W I AQILJ l T i u uCo i oval tun s to i r tlr tceuluttccut <br />