Laserfiche WebLink
QTSC. 0285 ?• (J12�� <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL 0 0 0 3 3 0 4 2 3 1 (800)4249300 013085121 JJ K <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> TRACY CHEVROLET Q&M INC <br /> 3400 AUTO PLAZA WAY <br /> TRACY CA <br /> 209 835500 95304 <br /> Generators Phone: <br /> 6,Transporter 1 Com an Name U.S.EPA ID Number <br /> ASBURY?�VIt20NMENTAL SERVICES CAD 0 2 9 2 7 7 0 3 6 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8. nVOQatedand TECHNOLOGIES LLC U.S.EPA IDNumber <br /> 5375 SOUTH BOYLE AVENUE <br /> LOSANGELES CA 90058 CAD097030993 <br /> Facility's Phone: (3231277-1500 <br /> 9a 9b.,U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Ouantity WtNol. <br /> ' NON-RCRA HAZARDOUS VVA.STE,SOLID(OILY SOLIDS) 352 <br /> I DM s� P <br /> z 2. <br /> W <br /> t' <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> EMERGENCY CONTACT:CHEMTREC 1-800424-9300 NAERG#981:171*PROFlLE'W98i:AP19i625 OILY <br /> SOLIDS * P0#OA1iUi95i64*APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT <br /> A� x5 - 0 11 X52 <br /> 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 classrhed,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national govemmental 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 EPAAcknowiedgment 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)(if I am a small quantity generator)is true. <br /> GeneratoeslOfferoe me Signature Month Day Year <br /> 10211 a l <br /> 16.Intemational Shipments <br /> F ❑Import to U.S. El Export from Port of entryle>at: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> CZ 17.Transporter Acknowledgment of Receipt of Materials <br /> Transpo Prinledrr ed Na Signature Month Day Year <br /> a <br /> CAI <br /> -Transporter 21Printed[Typed Name re Month Day Year <br /> C <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> U <br /> LL Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> CD <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. � 2. 3. 4. . <br /> F!! <br /> Faality Owner or 0 rator Certification of receipt of hazard m covered by the manifest except as noted in Item 1 Name Signature Month Day Year <br /> WI)e', I rCE " 2 <br /> EPA Form 8700.22(Rev.3-05) Previous edi'ons are o sole e. DESIGNATED FACILITY TO DESTINATION STATE (IF REOU ED) <br /> 11763.1575 <br />