Laserfiche WebLink
E <br />Please Drint or Woe. (Form destaned for use on elite (12-oitchl tvilawriter.1 - <br />E <br />F^rm AnnmvaA ouR Kin qnrnnnqa <br />r ruini oiuu-zz timev. -5-ua) rravious; eumons are oDsoieie. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORIA HAZARDOUS 1. Generator 10 Number <br />51 13 6 a 6 '& 4 4 <br />2. Page I of <br />3. Emergency Response Phone 4. <br />1 <br />"Ifest Trac"' Number <br />N2O665. <br />WASTE MANIFEST 1 <br />(8-17.) -577-2 6150 <br />0077gJJK <br />5. Generatoes, Name and Me! Addrrss Generatofs SiteAddfess (if different than mailing address) <br />MCDOVALB STATI011 'DONALD ISLATID <br />W.DAVY ON1f, 1- <br />�GFAE ZU(;JT41AT? F <br />P 0 B(X< 11.16 11T, 1, 95234 <br />CA 05234 A/11, 6% Z1 �1141601 <br />(BOLT. <br />eravelphone: <br />__- EPA1DNumber - <br />Philip llf.--st Induutrial servici;--u C A 1,- 0 5 1 <br />7. Transporter 2 Company Nam U.S. EPA It) Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />CIMMICAls NA37Z 14ANACEIAIKINT, IVC <br />35251 DILD 3KYLTNE ?'DAB CAT i)006546117 <br />X-ETTLE1,11AN CITY, (_'-A, Pt3239 <br />FaciliVs Phone: 800) 2'22-2�9iE <br />ga. <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />111. Total <br />12. UnA <br />H1.1 <br />and Picking Group (d any)). <br />Quantilty <br />WLPM. <br />(-0. Waste Codes <br />Type <br />11011 RCCA PJAWIM, SOLID (SOIL/F)EISRIS <br />6 <br />14IT11 OIL, TPH, 1)1ESEL, ETC <br />rs 14 <br />'7 go <br />P <br />LU <br />2. V <br />0 <br />�je- �-S 24 4L <br />qdq <br />4. <br />14, Special Handting Instrijefons and Additional Information <br />15. GENERATOKSIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully -andacwraWy describeil above by the propershipft -name, and are classified, packaged, <br />marked and labeledfoacerded, and are In aft respects in proper oemlitien for transport accoiding to applicable International and national gomilmentai 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 EPAAdmvAe"nl of Consent <br />I car* that the waste dnrmitzaflon statement identified In 40 CFR M6.27(a) (41 am a large quantity generator) or (b) (d I am a small quantity generator) Is bue. <br />GenerialotslOfferoesPdntedf Name Month Day Year1/0 <br />Alll'&Aakl`do� Wo0old <br />-j <br />16. ratermational shipments ❑ <br />❑ <br />Import to U.S. Export from U.S. Port of enW"t <br />Transporter signature (for exports only): Date lea4lg U.S.: <br />17. TirensportarAdwMAment of Receipt of Materials <br />Transporter I Ptintedlityped Name Signature Month Day Year <br />16F I& ya) <br />Transporter 2 Pdntedffypad Narae Signature Month Day Year <br />I& Discrepancy <br />i8a. Discrepancy Indation Space El Quantity [:]Type Residue ElPartlal Re;ectlon ❑ F.1 Rejection <br />Manifest Reference Reference Number. <br />m6.�Ad-y(or Generator) U.S. EPA ID Number <br />tJ <br />Facility'. Ph... ;r <br />L@ <br />Ll <br />W"Signature ofAltemate Fa 61-Ity (or can -a- I-) <br />Month Day Year <br />Z <br />y19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment disposal, and tecycling systems) <br />1. <br />2. <br />4. <br />20. Designated Facility O. -mer or Operator CeNcatibn of recelptol hazardous materials oovqred by the manifest except as ncted In Item 18a <br />Printedfiyped Name Signature Month Day Year <br />r ruini oiuu-zz timev. -5-ua) rravious; eumons are oDsoieie. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />