Laserfiche WebLink
Form Aoproved.OMB No.2050-0039 <br /> lite(12-pitch ewriter.) kin Number <br /> n e P Trac <br /> Please print or type.{Form designed for use o ( P 2:page 1 of 3.Emergency Response Phan, <br /> 4.Manifest g <br /> 1 nerator M Number 0000612 I <br /> UNIFORM HAZARDOUS (Z C j 7 i C19 Q ��� � ` <br /> WASTE MANIFEST < , <br /> Generators Site Address(if different than mailing address) <br /> 5.Generators Name and Mailing Address [jC h <br /> iFtk�U E6T r 'rt�iC� t�MIFIal)I i<.?i�s"t <br /> LCx> SIS ► ST Comm, <br /> Cq` i..� �4Ca, t5 :1S3l-1�tGl� <br /> Generator's Phane: U S'.EPA 1D Numi>er, <br /> H, <br /> 6.Transportef•-1 Company Name ' <br /> } U.S- <br /> C43 S.EPA r f 1 <br /> 7 Transporter 2 Co 4 <br /> t1.S.EPA ID.Number <br /> 8.Designated Facility Name and Site Address <br /> 14'187'E.i rlanttin> , Pariter, 0'+ 93648 I <br /> Facility's Phone; <br /> 10.Containers 11.Total 12.Unit 13,Waste Codes <br /> 8a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, No Type Quantity ' Wt.Nol. <br /> HM and Packing Group(lf any)) <br /> 0 1 N ON .RCR A Hazardous Waste, �J <br /> 'xeci t7iT 001 CT <br /> iL' <br /> lx <br /> Li <br /> Liquid <br /> L;yed f� ) <br /> W <br /> Z 2. <br /> r1J <br /> y <br /> ik <br /> 4 <br /> 14.Special Handling Instructions and Addttional informal on , <br /> Wear protective Clothing <br /> Emergene�+ReSprinse { <br /> Cnn#aet- San.Joaquin Filter F,ec�vcl'in <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignor c e a d d u ely described above by the proper shipping name,and.are classified,packaged, <br /> marked and labeledlplacarded,snd are in all respects irrpsoper condition for Iransporl according to applicable intemationai and national govemmental regulations.If export shipment and t am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached quAAck generator) <br /> (b Consent g generator)is true. s <br /> I certify that the waste minEmizabon statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity g ) Month _Day,,,,_.,-Year', <br /> ;Signature. � 1� <br /> Genera_torslOfferos Pdnfedrryped Name ) <br /> lex t: <br /> 16.Intema,)nal Shipments Impost to U.S. ❑Export i S. Port to entry <br /> F - - Date leaving U.S.: ' <br /> Transporter signature(for exports only): <br /> 17.Transporter Acknowtedgment of Receipt of Materials Month Day .Year. <br /> Transporter 1 Pr'tedrr d ame Sig of } <br /> Is!� <br /> ptZ Month Day Year <br /> QTransporter 2 PtintedrTyped Name Signalur <br /> H _ <br /> E 18.Discrepancy <br /> I ❑Type ❑Residue Partial Rejection Dull Rejection <br /> i 18a.Discrepancy Indicatson Space D Quantity <br /> Manifest Reference Number. ' <br /> U.S.EPA ID Number <br /> 18b.Ahemate Facility(or Generator) <br /> QMonth Day Year <br /> � <br /> Facility's Phone: <br /> OL 18c.Signatureof Aliemate Faality(or Generator) . <br /> z <br /> N19.Hazardous Waste Report Management Method Codes(Le,,codes for hazardous_waste treatment,disposal,and recycling systems)3. 4• <br /> LU <br /> 1 11141 2 <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous mateda4s covered by the manifest ex pt as din item 18a. Month i)ay Year <br /> PnntedlTyped Name Signa re <br /> L <br /> FPA Form 8700-22(Rev.3-05) Previous editions are obsolete. n=renpjwren Cer-11 1TV Tb.GENERATOR-_ _ <br />