Laserfiche WebLink
a <br />Please print or type. (Form designed for use on elite ( h) typewriter.) <br />46, <br />NIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of <br />WAST€ MANIFESTi)68�5`72Generator'sName and Mailing Address <br />OPCHARD H/S 055,265 NORTH MACA1 1't��. R i�Rs:iti.' TRUCE{ S1 OP/WAP161i ll <br />TRACY CA 35376 <br />enerators Phone:T,f f' feT1} n Ell SYSTEMS. <br />7 <br />argency Response P <br />itor's Site Address (If <br />mailing address) <br />U.S. EPA lit Nu <br />Form Approved. OMB No. 2050-0039 <br />ng Number <br />4.21131SKS <br />TXR(r000509 30 <br />B. Designated Facility Name and Site Address r1 g; y, SYSTEMS, INC 0007160 U.S ,EPA IDNumber <br />60060TH STREET <br />SACR�.{�E�ITt? CA95626 C�,C3f 00084517 <br />Facility's Phone: <br />9a. 9b. U.S. DOT Description (including Proper Stopping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit <br />13. Waste Codes <br />HM and Packing Group (if any)) No. Type Quantity Wt.Nol. <br />1. 14ON RCCA HAZARDOUS WASTE, LIQUID <br />a <br />ETHYLENE GLYCOL SOLUTION (LESS THAN 50%) } .. <br />a <br />Z <br />17 <br />LU <br />c� <br />SK TRCY#11 55'0 64 <br />00,02882503- <br />-11'V AEl°F'F;OR'X%EP TO RETAIN LICENSED SUBSEQUENT CARRIERS AS NECESSARY <br />15. GENERATOR1101"FEROR'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. ff export shipment and 1 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 262.271(11 1 am a large quantity generator) or (b) (ff I am a small quantity generator) is trite. <br />Generat s101feroes PrintedlTypedName Sig ature % Month Day 9 Year <br />18. International Shipments❑ Import to U.S. El Export from U:5. -P'ort- <br />of entrylexit: <br />Transporter signature (for exports only): Dale leaving U.S.: <br />17, Transporter Acknowledgment of Receipt of Materials <br />Year 1 <br />18. Discrepancy <br />183. Discrepancy Indication Space ❑ quantity ❑ Type ❑ Residue ❑ Parti6l Rejection ❑ Full Rejection <br />Manifest Reference Number; <br />18b. Alternate Facility (or Generator) U.S. EPA ID Number <br />Phone: <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />1. H 14 i 2. 3. 4. <br />20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 16a <br />Printedffyped Name Signature Month Day Year <br />ElF42$70p.;;�4l3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />