Laserfiche WebLink
/Approved.OMB No.2050-0039 <br /> PLt5Gaw.WsN� <br /> '0'0""e <br /> (Form deSlgned for use on die(12-M�)type'w'riter.) <br /> ARDOUS 1'Generator ID Number 2.Page 1 m 3.Emergency Response Phone L4 *I,ggNTrackMg Numtier <br /> NIFEST CALOWM193 1 WQ-7411W 000897753 G B F <br /> me and Megirg AddressGeheaurs NeeNoo,vz(8 dom enl Nan s)DOUBLE A TRUCK B TRAILER 9EWCE 187z W CHARTER WAP.o.SM 1402 STOCKMK CA SM <br /> DISCOVERY BAY.CA 945N <br /> pe;.�EW-4d7-DQI� umber1 Company NameSHOP tOZARDS SOLUTIONS,INC7.Transporter 2 Company NameNumber a.Desgaled F Name and sae Add es5 CORDOVA.ttL.C. Nu Ne <br /> Facilitvs Phone: <br /> fl49 361-OflBD <br /> 98. 9b.U.S.DOT Ddsviption(adudng Prow ShPPrg Name,Hazard[lass.ID Number. 10 Cmtapers, <br /> HM and Padug Grop(rt any)) <br /> 1. 1 Qw T .. 2= <br /> M ABSORBENTS 6 OL <br /> ¢O <br /> K <br /> Z Z. <br /> w <br /> CD <br /> 3 <br /> 4. <br /> GE has fhcw 3rir ro r <br /> 14.5a ____hermits for, a_n_cf Will as p - <br /> - - - <br /> APPROPRIAT6 PROTECTIVE SERVICE the waste this generator is <br /> SEE ERG 0115. GENERATOR'SIDFFEROR'S CERTIFICATION:Itweby dedare that the contents of this consignment are fuly and a zumidy desdbed Lh"MV59shipping name,and a%'dassufipd;packaged, <br /> marked and IabeledlpleraNeQ and are in al m3pects in proper condition for transport amordug u applicable intemaboaaland natural govemnientd regulations 8 exportshipmenl4ltd)Bmkre,Primary <br /> Exporter.I certity that the contents of Ns catsgmeut cmunn to the bimrs at Ne attadred EPAAdmowledyrienf of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(x)f8I am a large Wantity generator)or(b)full art a small quantity generator)s true. <br /> Genealoe PdratsNi Name SigiefUrp • Momh Day Year <br /> .T 7y l <br /> 18.Imematun shipments ❑Imupon to U.S. ❑Export from .S: Portofmbykxm <br /> Transporter signature(forpVors only) Date lea'd9 US <br /> w 17.TarepaterAdmwWedgium of RecalmofMaterials <br /> Tans 1 PdntedrT Sig"ure R N Day Year <br /> a Q <br /> = Trangpblter2 PML%MTYOW'Name Sigatune Day Year <br /> Q <br /> C <br /> t— <br /> } 18.Disvepancy <br /> 188.Di&xryagry IM[a3m;pace ❑ ❑Type ❑Residue ❑Partial Rejection Fug Rejection <br /> MamW Reference Number: �... <br /> 18b.Alternate Faddy(or Gerwrator) U.S.EPA ID Number ' <br /> J <br /> U <br /> 1 Fadliys Pfine: <br /> W 78c.Sgnah+e of Alternate Fadfmy(or Generator) Monty Day Year <br /> Q <br /> Z <br /> .0.:19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazard"wase treatment,deposa4 and recycling systema) <br /> 20 Desijpatetl,Farafty0werorOperaur.Cmti&atumof rereipl afhazaidars materials covered by the man"ejcW as ndad u Item 18a <br /> !tName Sigrefu Monty Day Vear <br /> 6ypY nLaf) lid fiv WTsL <br />