Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch) `ter.) Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number I 2 Page 1 of 3-Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C A L 0 0 0 .3 5 4 7 6 6 1 (800)424-9300 008368385 JJ K <br /> e Na a Ma cl Generators Site Address(if different than mailing address) <br /> J �P At 4° �;NTFRS r HOLT,v MART SwF) FLYTNG A 61.866 <br /> P.O. BOX 10146 KNOXVTT,T,F; TN 37939 1.901 NORTH .TACK TONE ROAD <br /> Generators Phone: (865) 588-7488 R ioAl/ GA —7 .53 <br /> o.Transporter 1 Company Name U.S.EPA ID Number <br /> CAT,TFORNTA HAZARDOUS SFRVTCFS CAR000209023 <br /> 7.Transporter 2 Company Name U S.EPA ID Number <br /> 8 Designated Faolily Name and Site Address U S.EPA ID Number <br /> Croshv K Overton; Tnr.. <br /> 1630 W. 17th St. r ona Reach, Ca. 90813 CATX028409019 <br /> Fadlity's Phom: (562) 4.12-54453 <br /> 9a. 9b.U S.DOT Desatption[including Proper Shipping Name.Hazard Class,ID Number, 10,Comamers 11.Total 12.Unit <br /> and Packing if an 13.Waste Codes <br /> HM 9 Grou P( Y)) No. Type Quantity WtNot. <br /> 0 <br /> W , <br /> W 2. <br /> I <br /> 3. <br /> 4 <br /> 14.Special Handling Instructions and Add I Information �? �j <br /> R1-U'C,o R�� 1'� � PQS'#x/70 APPROVAL #- APPROPRTATF TNG/R.SPTRATOR <br /> f4w' 24 HOUR RMFRGFNCY CONTACT: <br /> d RTLL TO: CAL-HA7 CHFMTRFC - 800-47.4-9300 <br /> 15 GEN ERATOR'S10FFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fury and accurately desrnbed above by the proper shipping name,and are ciassiRred,pack3ged• <br /> marked and tabeled/placarded.and are in all resp"in proper condition for transport according to applicable mtema'.ional and national governmental regulations.If export shipment and I am the Primary <br /> Exprxter,I certify that the contents of this consignment conform to the terms of the arixhed EPAAeknowledgment of Consent <br /> I certify that the waste minirnization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(d I am a small vantity gents or)is true. <br /> GeneratorsrOfferors PrinledlTyped Name S g ire Month Day Year <br /> t ham- �I 0 c--LC / I ! 3 Vz- <br /> Inle venal Shipments <br /> 1— I <br /> m <br /> p <br /> o <br /> rt to U.S. Export from U.S. Port of entrylexil. <br /> Transporter signature(fur exports only): Date <br /> w 17.Transporter edgment of Recei of Materials <br /> TranspoRer i P i yped Name re y month Da Year <br /> t l <br /> z <br /> Q er Trans 2 Pnnied/Typed Name S' lure Month Day Year <br /> r- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Refection ❑Full Re}ectwn <br /> Manilesl Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> u- Facility's Phone: <br /> in i Bc.Signature of Atlernate Facility(or Generator) Mond Day Year <br /> 4 <br /> 2 <br /> 0 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> V) <br /> w 1 2. 3. 4, <br /> r� rL# <br /> 20.Designated Facility Owner a Operator.Certification of receipt of hazardous materials covered by the manifest except as rutted in Item 18a <br /> Prin yped Nameignature hilonth y Year <br /> le CCP . © /P <br /> COR C1..1..07nn'N/0-11)AV D—:—... n.....i.l. j— _—_._ _J <br />