COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

Please print or type. (Form designed for use on elite (12 -pitch) typewriter,) Form Approved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3.05) Previous editions are obsolete. UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response one 4. an es Tracking Number WASTE MANIFEST CAL 0 0 0 3 8 8 5 3 8 1 (80 36&4778 012850228 J J K 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) QBR INC 2325 W CHARTER WAY 2325 W CHARTER WAY STOCKTON CA 95205 STOCKTON CA 952DB Generator's Phone: 209 467'0490 6. Transporter 1 Company Name U.S. EPA ID Number ENVIRONMENTAL RECOVERY 5ERVICE5, INC. CAR 0 0 0 1 8 8 2 0 1 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number U5 ECOLOGY HuVY 95,12 MLES SOUTH BEATTY NV 1 Facilitys Phone: (7775553-2203 N V T 3 3 0 0 1 0000 ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Pecking Group (if any)) Quantity Wt.Nol. 1. NON RCRA HAZARDOUS WASTE, LIQUID (OIL SLUDGE) 225 a 1 D M 5S -b P W 2. NON RCRA HAZARDOUS WASTE, 50LID (SHOT BLAST FILTER5) 1Et1 0 DM 100 P 3. 4. ;rs+^r 14. Special Handling Instructions and Additional Information S S 901107-013-1570-1732 - OILY SLUDGE i� ERGM: 981. 171, 982. 171 "ER5 W.O.# 103793 - ECS' 38'107-012-8391-1578- SHOT BLAST FILTERS %ALTH - IRO5ERV 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described SAWFyme. and are classified, packaged, marked and labeled/placarded, 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 Exporter, I certify that the contents of this consignment conform, to the terms of the attached EPAAcknowledgmenl of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. Generator's/Offerors Prinled[Typed NNap+me Signa re Month Year )Day jbo =-j Z 16. International Shipments ❑ Impart to U.S. ❑ Export from YS. Port of entry/exit: - Transporter signature (for exports only): Date leaving U.S.: W 17. Trans flerAcknowledgmenl of Receipt pf Materials Transer 1 PrintedFryped Na a Signet a Month Day Year CL i ^ �'() 7 1 Zer rntec ypedName Sign Month Day Yea Q t- 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection El Full Rejection Manifest Reference Number 18b, Alternate Fecillty (or Generator) U.S. EPA ID Number J v U<- Facility's Phone: w 18c. Signature of Altemate Facility (or Generator) Month Day Year a z 19, Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) 0 1. 2. 3. 4. 20, Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedfTyped Name Signature Month Day Year EPA Form 8700-22 (Rev. 3.05) Previous editions are obsolete.