COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

Please print or type.(Form designed for use on elite(1 -pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST L O Q � -b 3 50-103- 9 3 000257466 M W I 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) �LoGAL M-ATEKIA HA-t4AC1CMC-AIT LL(-, Ibl,�r u) iJ 9 Y:(3A-Pl /Vv(-' t64o, N, f3KoAD�iftvC,, ,STOC—VJ A/ Generators Phone: 0 3 - X36 c C--A --9 �-40-- �-e) c�-��b A)� L.A 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number 25'00 W LO ESN "i QUITOA( JILLoIJ,CA 0122 Facility's Phone: 6� q6 )-- 6 I-t),o 0_.A D9 0 6,15 2-b 5 ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12 Unit and Packing d an 13 Waste Codes 9 Gmu HM P 1 Y)) No. Type Quantity Wf.No,. 1. lZ O S - —— ---- - I�1DN-�c�A WACrF, SoLro t)0 ) Cr{ 2(5 Z 2. W 0 3. 4. 14.Special Handling Instructions and Additional Informati n pr�p�F t LL � CH 1 �s Z►s•I3 V PC 15 GEN ERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and acc mately described above by the proper shipping name,and are classified,packaged, marked and labeledrplacarded,and are in all respec s in proper condition for transport accerdicg to applicable internalional and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attacned EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a Targe quantity generator)or(b)(if I am a;mall quantity generator)is true. GeneralorslOfferors PdntedlTyped Name Signature Month Day Year 16.International Shipments ❑Import to U.S. ❑Export from U.S. Port of entrylexlC Transporter signature(for exports only): Date leaving U.S.: LO: 17 Transporter Acknowledgment of Receipt of Matenals K Transporter 1 PnntedlTyped Name Signature Month Day Year O a Q Transporter 2 Printed/Typed Name Signature Month Day Year r 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity LJ Type L Residue LJ Partial Rejection Full Rejection Manifest Reference Number. 18b.Alternate Facility(or Generator) U.S.EPA ID Number J Facility's Phone: L 18c.Signature of Alternate Facility(or Generator) ".lonth Day Year Q Z n 19.Hazardous Waste Report Management Method Code (i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by a manifest except as noted in Item 18a Pnnted/Typed ame Signature Month Day Vear 'A Form 8700.22(Rev.3-05) Previous editions are ot�solete. DESIGNATED FACILITY Tri nFCTlnre7rnnr C-rR,c nr err •