Laserfiche WebLink
s, <br />.7 <br />Please print or type. (Form designed for use on elite (12 -bitch) tvbewriter.) <br />• <br />Fnrm A AAAo Ki )nrn <br />EPA Forel 8700.22 (Kei 3-05) Previous eattionS are Obsolete. <br />GENERATOR'S INITIAL COPY <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />2. Page 1 of <br />3. Emergency Response Phone 4. <br />Manifest Traking Number <br />WASTE MANIFEST <br />CAL, 0W 302 524 <br />1(559)647-0353 <br />001 515079 JJ K <br />5. Generator's Name and Mailing Address Generator's Site Address (tf different than mailing address) <br />Internationftl AUto Dismantling <br />3725 Massino Circle 930 E. Charter Way <br />Stockton, Ca 95212 (209)747-5553 Stockton, Ca 95212 <br />Generator's Phone: <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />Oil Conservation Service, -Inc. CAIS 980 673 642 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />Riverbank Ail Transfer, LLC <br />5300' Claus road <br />Riverbank: Ca 95367 (209)863-8.18. CAL OW 190 818 <br />Fadlity's Phone: <br />ga. <br />9b. U.S. DOT Description {including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (if any)} <br />Quantity <br />Wt.Nol. <br />13. Waste Codes <br />No. <br />Type <br />o <br />1. <br />NON RCRA HAZARDOUS WASTF': r LIQUID <br />001 <br />IT <br />G <br />221 <br />(used oil/mixed oil)15 <br />W <br />z <br />2. <br />W <br />c� <br />3. <br />4. <br />14. Special Handling Instructions and Additional information <br />&qG# I'll <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately deschbed 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 EPAAcknowledgment 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} ('d I am a small quantity generator) is true. <br />Genemtor'slOfferor's Printed/Typed Name Signature . �.r Month Day Year <br />16. International Shipments ❑ Import to U.S. ❑ Export from U.S. Part of entryfezlt: <br />M <br />Transporter signature (for exports only): Date leaving U.S.: <br />CC <br />17. Transporter Acknowledgment of Receipt of Materials <br />Transporter 1 PrintedrTyped Name Signature Month Day Year <br />ZX <br />za <br />Transporter 2 PrintedlTyped Name Signature Month Day Year <br />H <br />18. Discrepancy <br />18a. Discrepancy Indication Space El Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br />Manifest Reference Number: <br />1Bb. Alternate Facility (or Generator) U.S. EPA ID Number <br />V <br />LL <br />Facility's Phone: <br />ul <br />18c. Signature of Alternate Facility (or Generator)Month Day Year <br />a <br />Z <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LU G <br />1. <br />2. <br />T <br />4. <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Pnnledrryped Name Signature v Month Day Year <br />EPA Forel 8700.22 (Kei 3-05) Previous eattionS are Obsolete. <br />GENERATOR'S INITIAL COPY <br />