Laserfiche WebLink
State of CalSforn la—Health and Welfare Agency Department of Health Services <br /> Toxic Substances Control Division <br /> r Sacramento,California <br /> Please print or type. (Farm designed tot use on elite(12-pitch)typewriter.) <br /> UNIFORM HAZARDOUS enerators o. ani est age Information in the shaded areas <br /> WASTE MANIFEST Document No. is not required by Federal <br /> of Is <br /> enerators Name and Mailing Address A Sta a enifest Document Number <br /> California Dept, of Transportation <br /> 1976 E. Charter Way, Stockton, CA 95201 e. tateGenerator's I <br /> 4. Generator'sPhone ( ) <br /> ransporser ompany Name US EPA ID Number C.State ransporter's ID �„ire, ^• .r/ <br /> - : ....�,: ^f ransporter's hone-.-.,r;, ,g..: <br /> 7. <br /> Yansporter ompany Name 8. US EPA ID Number E. tete ransporter's D <br /> . . ransporter's Phone <br /> 9. Designated Facility Name and Site Address US EPA ID Number G.StateFacility's-ID <br /> Chem Waste ManagementA 4' <br /> 35251 Old Skyline Road acihtys hone <br /> Kettleman Hills, CA 93239 1 C A T 0 0 0 6 4 6 1 209 386-9711 <br /> 12.Conta iners <br /> 11. US DOT Description(Including Proper Shipping Name, Hazard Class, and ID Number Total Unit Waste No. <br /> No. T e Quantity <br /> G <br /> E 8. <br /> E Hazardous Waste Solid, N.O.S. , ORM-E, NA 9189 001 DT Y , /,/ <br /> ro. <br /> fl <br /> A b <br /> T <br /> 0 <br /> R <br /> C. <br /> d. <br /> J Addlbpnel Deacriptlona or ateriala Usted Above K,Handling Codes for Wastes tst ve ' <br /> lid M0 a z <br /> Sails{c Ain ale wi h 'cliesel fuel. Profile #F26251 <br /> pecla andlmg nstructlons and dditionel n ormauon <br /> 1 ER A I N:I hereby declarethatthecontentsofthisconsignmeM ere ully and accurately described <br /> above by proper shipping name and are classified,packed,marked,and labeled,and we in all respects in proper condition for <br /> transport by highway according to applicable international and national governmental regulations. Date <br /> Month Day Year <br /> Printed/Typed Name Signature <br /> 7 z <br /> _ _ i <br /> T 17.Transporter 1 Acknowledgement of Receipt of Materials Date <br /> R Month Day Yea <br /> A .--Printed/Typed Name Signature // <br /> 0 18:Trensjorter 2 Acknowledgement or Receipt of Materials - - Date <br /> R Signature ._Y Month Day Year <br /> T Printed/Typed Name <br /> E f l 71 <br /> R <br /> 19. Discrepancy Indication Space 7-4 <br /> F ill <br /> A 2 <br /> C <br /> I 0d <br /> t 20.Facility Owner or Operator: Certification of receipt of hazardous materials covered t}y thj0({pat)71est'Ie�cfa asr�t9ted In <br /> T Item 19. kr -t Yf Date <br /> y - <br /> Printed/Typed Name Sig t to Month Day Year <br /> r vi r .l : <br /> a <br /> J <br /> DHS 8722 -2 17/84> Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS t <br /> TEPA 8700-22) <br />