Laserfiche WebLink
Please print or type.(F rm designed for use on elite(12-pit ewriter.) Form Approved.OMB No.2050.0039 <br /> .} UNIFORMHAlARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest TraeklNumber <br /> WASTE MANIFEST 3D'F 7 3--'OS 0 01 �.11.0 91. JJ K <br /> 5.Generators Name.and Mailing Address Generators Site Address(if different than mailing address) <br /> Generator's Phone: <br /> fi,Transporter 1 Company Name U.S.EPA ID Number <br /> 7.Transporter Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Facility's Phone: <br /> 9e. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) ryo, Type Quantity WIIVOI. <br /> 1vYr4ar r-'.t ;;.: '.F.-.d.14141H-IV-O -.p✓-NPN ..}3..p6µ bP.9 G1'. Tit<7•. <br /> fSYr <br /> Z 2. <br /> THIS WASTE STREAM HAS BEEN QUALIFIED <br /> 3. FOR RECYCLING;jTRF9MFNT ATTHE <br /> DeMENNO/KERDOON FACILITY IN COMPTON, _ <br /> CALIFORNIA.THIS FACILITY HAS THE NECESSARY <br /> 4. <br /> QUALIFIED. OUR EPA NUMBER IS CAT080013352 <br /> 14.Special Handling Instructions and Additional Information <br /> -•'.TION 24 H(^l!F ENIFRfdNCY CONTACT CHENITREC aW-424-oli .I AND CHICO ORNN OIL SEWACE <br /> 15. GENERATOR'SIOFFEROR'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 certffy that the contents of this consignment canksm to the tens of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(H I am a large quantity generator)o (6)(f I am a small quantity generator)is We. <br /> Genemtors/Offe rs PdntedlTyped Name Signature i Month Day Year <br /> r <br /> 16.International hipm'ntsEl Im - <br /> _ pod to U.S. � El ham U.S. Port of entrylexfl: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt ofM tartlets <br /> Transporter 1 Prinledrfyped Name Signature Month Day Year <br /> r <br /> QTransporter 2 PdntedfTyped Name Signature Month Day ' Year <br /> K <br /> H <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type <br /> ❑Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V - <br /> LL Fbality'S Phone. <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment.disposal,and recycling systems) <br /> 5. <br /> 2. 3. 4. <br /> 1 20,Desgnated Facility Owner or Operator:Dedication of receiptof hazardous materals covened by the manifest exceptas noted in Item 18a <br /> Pri tedlTyped Name 1. Signature Month Day Yqar„ <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. bESIGNATED FACILITY TO GENERATOR <br />