COMPLIANCE INFO PRE 2019 - Laserfiche WebLink

Home Browse Search

State of California—Environmental Protection Agency Form Approved OMB No. 2050-GJ39 (Expires 9-30-99) See Instructions on back Of -e 6. Department of Toxic Substances Control Please print or type. Form designed for use on elite f 12 -pitch) iter. Sacramento. California DO NOT WRITE BELOW THIS LINE. Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. DTSC 8022A (1/99) (Generators who submit hazardous waste for transport out-of-state, EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.) UNIFORM HAZARDOUS 1. Generator's US EPA ID No. Manifest Document No. 2. Page 1 Information in the shaded areas WASTE MANIFE -t 010 lo :N! .,) • . , of is not required by Federal law. 3. Generator's Name and Mailing Address A. State Manifest Document Number 2286 B. State Generator's ID SlaC_ ,. ;` ;� r- 4. Generator's Phone I - ) '�)]` i [ ` r -" 5. Transporter 1 Company Name 6. US EPA ID Number C. State Transporter's ID [Reserved] -.%if,; • D. Transporter's Phone 7. Transporter 2 Company Name 8. US EPA ID Number E. State Transporter's ID [Reserved.] F. Transporter's Phone 9. Designated Facility Name and Site Address 10. US EPA ID Number G. State Facility's ID 1DEPENDEi,. [� J A R� .HIER'31 RE~E 1 H. Facility's Phone _1115 ` CA 11. US DOT Description (including Proper Shipping Name, Hazard Class, and ID Number) 12. Containers 13. Total Quantity 14. Unit Wt/Vol I. Waste Number No. Type State NON RCRA HAZARDOUS EPA/Other.. G •,A51 E 6i' J113 L - I � � C t � 7� 7 Nb. State E EPA/Other R A T O C. P>44 PANG State R 6(i'c1�tl J EPA/Other d. State N wo.,. EPA/Other p J. Additional Descriptions for Materials Li ave K. Handling Codes for Wastes Listed Above C. d. 15. Special Handling Instructions and Additional Information WEAP 13PE EMERGENCY CON ACT: KIRK HMWARD 1-)•111-4?6-'1740 ERG # 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper shipping name and are classified, packed, marked, and labeled, and are in all respects in proper condition for transport by highway according to applicable international and national government regulations. Ifam a large quantity generator, I certify that I have a proggram in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically have practicable and that I selected the practicable method of treatment, storage, or disposal currently available to me which minimizes the present and future threat to human health and the environment; OR, if I am a small quantity generator, I have made a good faith effort to minimize my waste generation and select the best waste management method that is available to me and that I can afford. Printed/Typgd Name Signature J Month Day Year i R17. Transporter 1 Acknowledgement of Receipt of Materials R Printed/Typed Name `a T �•. Tigriqture Month t Day Year P f I ` B 18. Transporter 2 Acknowledgement of Receipt of Materials R Printed/Typed Name Signature Month Day Year E R 19. Discrepancy indication Space F A C I L 1 20. Facility Owner or Operator Certification of receipt of hazardous materials covered by this manifest except as noted in Item 19. T Printed/Typed Name - 7-7,- ^, Signature , j month Day Year DO NOT WRITE BELOW THIS LINE. Yellow: TSDF SENDS THIS COPY TO GENERATOR WITHIN 30 DAYS. DTSC 8022A (1/99) (Generators who submit hazardous waste for transport out-of-state, EPA 8700-22 produce completed copy of this copy and send to DTSC within 30 days.)