COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

Please print or type.(Form designed for use on elite(12-p4ch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number - WASTE MANIFEST C A 1) 9 8 2-5 0 8 2 w z 000252725 JJ K 5.Generators Name and Mailing Address - Generator's Site Address(if dlflerent than mailing address) i I..Yrt#Fhi tJ11esf>i'>•t°1 G!'e'7ccwc U.W.G. AtM: Flat jSr~rTT1 ,,*52 SCS SIVA) �-;sseet 1990 Picco#R(I Gori •:rcf: CA 90040 ('A 95.'-21 '= Generators Phone: - me ,6.Transporter 1 Company MaU.S.EPA ID Numbef 7,Transporter 2 Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA 10 Number t VV. 'I ith$tToet Long Nweit CA 9W-13 Facili s Phone: r n '-"1 L`444 = C., 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12,Unit 13,Waste Codes HM and Packing Group(if any)) No. Type Quantity WLNol. f UN19%WASTE A'c'.rori0t3 PL AMMAftE 531 1 P 2. Ill! V 3. 4- 14.Special Handling Instructions and Additional Information _. �r);,. i i ;�;-er:�ti ..•.l." ',#'1. �lnr:.�',, )�-} .. 'I„p,l),t 1,.E- ��1,i�1".}, �F' °�l^ .) �� .,).t_SETt7,, tu, t:rt.J{3��t] �C, ;� a5 f 15. GENERATOR'S10FFEROR'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, ` marked and Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable intamational and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent I certify that the waste minimization statement identified In 40 CFR 26227(a)('d I am a large quantity generator)or(b)(If 1 arra a small quantity generator)is true. GeneratoeslOfieroes PrintedlType4 Name ; Signature ," Month Ray Year - ]" - ,f.' tet.t. - - ! •Y hN r"• �+ 16.International Shipments - F ❑Import to U.S. ❑Export from U.S. Port of entrylexit: Z Transporter signature(for exports only): Date leaving U.S.: ' w 17.Transporter Ac )oWedgment of Receipt of Materials Trans er 1 Printe3VTyped Name Signature Month Day Year O rd a Transporter 2 PrintedlTyped Name Signature •.. Month _ Day Year. 18.Discrepancy 18e.Discrepancy indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection 0 Full Rejection Manifest Refetenoe Number. 18b.Aftemate Facility(or Generator) U.S.EPA ID Number J .. Facilill/s Phone: Month. W ..Day Year 18c.Signature of Alternate Facility(or Generator) z N19.Hazardous Waste Report Management Method Codes(t.e,,codes for hazardous waste treatment,disposal,and recycling systems) 1, 2. 3• 4. 20.Designated Facility Owner of Operator.Certification of recelpt of hazardous materials covered by the manifest except as noted in Item 18a ' ' Printediryped Name Signature Month Day Year EPA Form 8700,22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL.COPY ��