Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitc\typewriter) \� <br /> 1.Generator ID Number Form Approved.OMB No.2050-0039 <br /> } UNIFORM HAZARDOUS 2,Page 1 of I Emergency Response tff <br /> Tracking NumberWASTE MANIFEST CA0002792087 1 916-371.57472 917 9 8 6 JJK <br /> S.Generator's Name and Mailing Address Generator's Site Address/ ss)J 1 H MARINE REPAIR �q ,yd01 N SAN JOSE Sf-6E�-11p 0 l�r. <br /> STOCKTON,CA 95203 <br /> Generator's PhoneM-496-4716 <br /> 6.Transporter 1 Company Name <br /> NAV 9 9. <br /> RAMOS ENVIRONMENTAL SERVICES INC. 1J Z Y EPA ID Number CADDd40pd556 <br /> 7,Transporter 2 Company Name <br /> ENVIRONMENT U HEALTH <br /> 8.Designated Facility Name and Site Address <br /> PACIFIC RESOURCE RECOVERY Ll 1 . .EPA ID Number <br /> 3150 EAST PICO BLVD. CAMOE252405 <br /> LOS ANGELES,CA 90023 <br /> Facility's Phone X1-499-7145 <br /> 9, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 11 Total 12,Unit <br /> 4No. Type <br /> HM and Packing Group(if any) Quntity Wt.Nol. 13.Waste Codes <br /> X 1 UN1203,WASTE GASOLINE,3,PGII --8� G 343 DW1 '0018 <br /> oNON RCRA HAZAROOUS WASTE LIQUID (OILY SLUDGE) <br /> G 343 <br /> 3. <br /> 4. <br /> 14.Special Handling 111,11 tip4, 1 Additional Information <br /> 9Bi)PROFILE# A ERG#128 9&2)PROFILE# 0 V. c G#171 <br /> E.R. CONTRACTOR: RAMOS ENVIRONMENTAL <br /> HANDLERS TO BE TRAINED AND USE PPE. <br /> 15, GENERATOR'S/OFFEROR'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.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 EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Gerreratoesq/Ofiemes Printed/typed Name Signature <br /> Month Day Year <br /> // Y CSG LCAT, 11� <br /> F .Internatio al Shipments ' r ' <br /> z ❑Import to U.S. ❑Export from U.S. i Port ofentrylexil: <br /> Transporter signature(tor exports only): Date leaving U.S.: <br /> w 77.Transporter Acknowledgment of Receipt of Materials <br /> yam, Transporter 1 rrilia,ullyipayiTe <br /> Sin to Month Day Year <br /> H e - <br /> 2 Transporter2—11ksWlypvu Nama <br /> Fsignature Month Day Ye <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type El Residue ❑Partial Rejection I ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number: <br /> ..a U.S.EPA ID Number <br /> U <br /> LL Facililys Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. 3. <br /> — 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the mani/est except as noted in Item Iso - <br /> PrintedlTyped Name Signature <br /> Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DE;SIGNAQ Ia FACILI7-Y TQ DESTINATION STATE(IF REQUIRED) <br /> 1+11n -161" till 510 ; 406 (o o I <br />