Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Gene r IDD yyu 2.Pa9e 1 of 3.Emergency Rgspopspl Phpne 4.Manifest Tracking Number <br /> WASTE MANIFEST L v 3 3 0 4 2 3 b 755 J J K <br /> 5.Genera CY} o� rye�Q&M WC Generator's Site Address(if different than mailing address) <br /> 3400 AUTO PLAZA 1�t11Y <br /> TRACA 95304 <br /> 209 M4500 <br /> Generator's Phone: �b <br /> 6.Transpor � <br /> a � *NTAL SERVICES U.S.EP6'Ab ft 8 2 7 7 0 3 6 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Faciliht Nameand Sitaeldd[e�s C U.S.EPA ID Number <br /> II5375 SOUTH JJS�f %EC <br /> L�G WEL YCMKIrUiAY�I.NUE CA 90MR EQ <br /> p 0 9 7 0 3 0 9 9 3 <br /> Facility's Phone: (329)277-1W n <br /> 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> o.. Type Quantity Wt.Nol. <br /> Z 2. <br /> w <br /> C7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> ..._L 14100-424.9900 NAERd9 881:171 *PAOFlLE N 861:AP191826-3 OILY PAPER FILTERS <br /> *P600 00028807 *APPROPRIATE PERSONAL PROTECTIVE EQUIPMENT <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,and are classified,packaged, <br /> 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 <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment 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]am a stDall quantity generator)is <br /> Generator's/Offerors Printed/Typed Name Signature Month Day Year <br /> J 16.International Shipments <br /> Z ❑Import to U.S. ❑Export from U.S. Port of er1try/exit <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> LX 17.Transporter Acknowledgment of Receipt of Materials <br /> Transpofter 1 Printedliypedf(aide Signature Month Day Year <br /> Cn <br /> ZQ Transporter 2 Printed/Typed Name Signature Month Day Year <br /> rY <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El <br /> Quantity El Type ❑Residue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> � <br /> 1. 2. 3. 4. <br /> { <br /> 20.Designated Facility Owner or Ope�ator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITYTO GENERATOR <br />