Laserfiche WebLink
Plea se print or type.(Form designed for use on elite(12-pitch)typewriter) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number <br /> TPa,e 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANEFEST ( U f,O f-1qJ ' G B F <br /> 5.Generetors Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> S31_CiBF�.Su�.�Td Ci>u C;Afi�G <br /> 4107 SPYGiA130-Did <br /> S EUt h:l's"lid. 8�2t 1404 t tdt f't F'h'v'r <br /> 'Ori-5�i'kR�,3T-31! .=FfUt.t.3t Ii,CA <br /> Generator's Phone: <br /> 6.Transporter 1 Company Name ti U.S, <br /> EPA ID Number <br /> _�)}()} fill..ctrl)i>:ijt.liTl }Fd ,1ti(: c"'glttlf3tffQ17 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facifty Name and Site Address U.S.EPA ID Number <br /> fa�t�f=A :Clitt CCrf;aCxvll,I.L.C'.- <br /> 11135!s Yui I F 46C:K Rt-1 cr¢ <br /> RMgCHO C'01RDOVA,CA P5742 <br /> 9113 <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Description(including proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Pacidng Group(H any)) No. Type Quantity Wt Vol. 13.Waste Codes <br /> 1 WN-RC-I=A hfY ClpLt,::'F {E ,+lllG DIV 15,4 <br /> 1 P 223 352 <br /> p (�uL PA;-,,s.[3 p r 8 DEGRi <br /> w <br /> Z 2. <br /> UJ <br /> C7 <br /> 3. <br /> 4. <br /> 14.Sectal HaindFng Insttrruuctions_and AdditionalInformation <br /> 2-02 <br /> ERG <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 labeledlplacarded,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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimlzatlon statement identified in 40 CFR 262.27(a)(ri 1 am a large quantity generator)or(b)(iff am a small fuanlitygenerator)is true. <br /> Genera rslOffero s PrinJt_edfTyped Name f,' l - Signature = r Month Day Year <br /> J 16.International Shipments <br /> 1.- 1:1 Import to U.S. ❑Export from U.S. Part of entrylexit: <br /> - Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter rinteJjedlJypedName ,f Signature , Mon /Da Year <br /> CL <br /> to <br /> Q Transporter Printedilyped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ ouai ty T pe Residue <br /> Partial Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Aitemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 4 � { <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU <br /> 1. 2. 3. Notice: State of California requires <br /> generator to photocopy and mail to DTSC <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Ite within 3 0 dayS: <br /> Printedrryped Name signature P.O. Box 400.Sacramento,CA 95812-0400 Year <br /> EPA Form 6700-22(Rev.3-05) Previous editions are obsolete. <br /> GENERATOR'S INITIAL COPY <br />