Laserfiche WebLink
Please prml or type (Form designed for use on elito (12-pitc "writer.) <br />Form Approved, OMB No, 2050-0039 <br />UNIFORM HAZARDOUS <br />I <br />1 Genamtor [D Nufter <br />0 1 0 3 2 <br />2 Page i of <br />3 Errmt nay Response Phone <br />4. Manifest Tracking Number <br />1005105401 JJK <br />WASTE MANIFEST <br />C A L 0 0 0 1 <br />tai) 424930 <br />1 <br />5. Gerieratoe* Narrem mrd Wiing Address Generator's Site ,Address (:f difforent than mast if addresa) <br />JIFFY LUSE O59F1 <br />1130 N. WN ST 1130NMYNST <br />P/PWTECA CA pk336 MV4TECA CA 9M <br />Generalor's Plidale 209 <br />e. Iftworief 1 Company Nana U.S. EPA ID Ndmlber <br />ASWRY EWRONWN TAL SERVICB C A 0 0 2 9 2 7 7 0 3 6 <br />7, Transporter Z ConVany Name U.S EPA ID Number <br />B. Designated FaaL,y Nene and Site Address US EPA ID Number <br />RAWS EtsWRONNENTAL <br />ROM) <br />(NEST SATCA 06W1 CAD Q 4 4 0 0 3 5 5 6 <br />Facility$ Phono: (91611371b74T <br />9, <br />gb U.S. DOT Descnpion {including Proper Shpping Name, Hazard Class, ID Number, <br />t0. Conlaners <br />11, Total <br />12. Unit <br />19 Waste Codes <br />No, <br />Type <br />HM <br />and Pack ng Group (d any)) <br />Quantity <br />Wt vol. <br />1 <br />223 <br />NON -ROM HAZARDOUS WASTE, UQUID {(XLY WATER) <br />G <br />001 <br />TT <br />w <br />t9 <br />3. <br />4. <br />r4. Speclal Handling Insbuclions and Additional information <br />NAER00 1381 171 ' PRORLE # 181 "AWTIONAL EPA CODES 981', NONE' APPROPRIATE PERSONAL PROTMIM <br />FOUiPWINT <br />15. GENERATOWFJOFFEROWS CERTIFICATION: 1 hereby declare That no c rdents of ttus comigmrenl are fully and aeoeraloly described above by the proper shipping name, erd are dau led, packaged,' <br />marked and laboladlplacarded, and aroIn all respects In proper condition fort wsporl according to app'lcatte intem doral and national govemmentai regulations. If expom shipnwt end 1 am the Primary <br />Exporter, I certify that the conbrds of this consngnmeni cordorm to tha terms of the eadnad EPAAckMWedgmenl of Consent <br />r fy that 8w :cast. mnimora5on statement denhfied in 40 CFR 262 27(a) (it I am a laKja quantiy genera4or) or (b) fir i am a small quantity generator) is truo <br />Genore 'Ofla rirt -ped Nome ^ S'B e ^ Ya <br />Om �� � <br />!/ <br />� ! S ` <br />^1 <br />(~ <br />16. Wainati&W S iprmnis <br />❑ import to U S ❑ Expd A from U.S. Pan of entryleel: <br />= <br />Transporier stgnatu a (for exports only) Data leaving U.S. <br />17 Transporter Addmowledgma�l of Ro*t of Matsrals <br />aTransporter <br />_ <br />1 nnjj,�It d me S'gnatu f M n2n eer. <br />Q <br />Transporter 2 Pnn (Typed ams Signatures Month Day Year <br />t- <br />18. Discrepancy <br />18a 01scrr4xancy Indication Space Quantdy ❑ Type Residue ❑ Partial R.),,. n ❑ Full Relaaon <br />Mani!ost Reference Number, <br />I 8h Aliamats Fadity, (or Generator) U.S. EPA ID Number <br />uQ. <br />W <br />.� <br />Faa(IlYs Phone, <br />18c. Signaboe of ArSemata Facitay (or Generamr) Montn Day Year <br />19. Hazardous Waste Report Management Method Codes (ie., codes for hazardous wsW treatment, disposal, and recycling systems) <br />f <br />2 3. <br />4. <br />ZO. Designs Facility Dunn or Operator. Cortcahon of pt of Mous matenals covered by the rnanftast!M!,0 noted in r 18a <br />rme ad /✓ /v //`L A '/,r <br />"? (QP <br />7;4� <br />nr-Qlr.M iffm j:eca.ITY TO GENERATOR <br />