Laserfiche WebLink
J <br /> Please print or type.(Formdesigned for use on elite(72-pitch } `ewriler.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.G e for 10 Nu ber 2.Page 1 of 3.Emre�rg�encyy'Resp nse Phone 4.Manife(st <br /> �7rasking Number �[- Q O r p i <br /> WASTE MANIFEST �U/ f I rV/: + � .ZOO 0 O 0 0 5 9 4 V J`^:D F <br /> 5.Generators Name and Mailing Address Gonerator's Site'Address jit differ nt than mailin�ddrass) <br /> s7MLer 6oximcra,6-- �C160 P�eCoi) i3n /P0.6�� 6D75-3 7M11 <br /> Generators?hone: Zcc <br /> _ iC�u �� `75Z( ::�►.� <br /> U.S.EPA 10 Number <br /> 6.Transporter 1 Company Name i <br /> .It;at u;tl.#�i.[t4.r Rec. ink C. Lt 431)'1 27 i <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> 8.Designated FacillpWj U.S.EPA ID Number <br /> 14287-E. L-du�g', Parlier, C.A_ 936-8 <br /> (55!1') 498-0240 :, . ' C�U-000102751 ;t = <br /> Facility's Phone: *_`F <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number; 10.Containers 11.Total 12,Unit 13.Waste Codes <j <br /> -HM and Packing Group(1f any)) No. Type Quantity Wt Nol. <br /> • 1. <br /> N ON ' R(.-RA azar nus Waste, 221 <br /> LU <br /> 2. <br /> LU <br /> r <br /> 3. <br /> 4. <br /> lisp, <br /> -.Special Handlin Ing truetio fl and Additional Infonrl tion, <br /> „ �'k ear T'rotectt� t, t, 1n� . 1�•tner; entry Re ?Ouse <br /> Contact- San kjaquin Filter Recycling <br /> 5 9 j <br /> 498-0240 <br /> 15. GENERATOR'SfOFFEROR'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 labeledlplacarded;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 minimizationstatement idenffed in 40 CFR 262.27(a)(If I am a large quantity generator)or(b)(ifl am Xmafl quantity generator)istrue. <br /> Genera_tc?sfOfferor rintedrryped Numb Signature * Month- Day Year <br /> 7y' Q d <br /> .-16.International Shipments - <br /> 1 ' ElImportto U.S. El Export from U.S. Port of enirylexit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> N°fransporterAcknoWedgment of Receipt of Materials <br /> Transporter 1 Prime dfr d Name Signature I Month Day Year <br /> O L. { • ' <br /> aTransporter rintedlTypedName Signature , Month Day Year. <br /> 16.Discrepancy , <br /> 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residue ❑Partial Rejection Full Rejection <br /> ~ - Manifest Reference Number:' <br /> 18b.Alternate Facility(or Generator) s_ U.S.EPA I0 Number <br /> U <br /> IaL Fadilly's Phone: <br /> w 18c.Signature of Altemate Fadl4y.(vr Generator) Monfh Day Year' - <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) . <br /> LLJ 1. <br /> H141 . <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in m 18a <br /> Pdntedfr Name <br /> Signa, e i Month .Day Year <br /> EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. IC <br /> nFr%infJaTCn Fectl-11TvtA iMFNFROTOR _..: '.. <br />