COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

0 0 6 1 9 2 0 4 3 S K S Please print or type.(Form designed for use on elite(12-pitch)typewriter) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS t.Generator ID Number T 5 2.Pagel 1 of 3..Emergency Response Phone 4.Manifest Trackln Number WASTE MANIFEST R000082�0.- 1006192043 SKS 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) VS7 INC. 1 ETV—F'L 'A9-545-101] CA 95368 Generator's Phone: SAL IDP — - s.Transporter t Company Name SYSTEMS INC U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address SAFETY—KLEEN OF CALIFORNIA U.S.EPA ID Number 6880 SMITH AVE. NEWARK , CA 94-60 520-795--4480 CAR98088?4';', Fadliys Phone: ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit HM and Pecking Group(if any)) 13.Waste Codes Na. Type Gull Vill K 1. R71)NI O F z i v z w CD 3. 4 14.Special Handling Instructions and Additional Information N. 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are dassified,packaged, marked and Iabeledlplacarded,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 EPA Acknowledgment of Consent.. I partly that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ff l a s 'quantity generator)is true. Gener rslOfierors Pnn(edlfyped Name Signature Month Day Year os 1'7 -u! 16.International Shipments F ❑Import to U.S. ❑Export from U.S. n olentrp = Transporter signature(for exports only) to l9eving U.S.: W 17.Transport Acknowledgment of Receipt of Materials OTransporter 1 P acIfTyped Name Signature Month Day Year a �•vv.q r 0 O h Transporter 2 Pnntetl/fypetl Name Signature Month Day Year C f j18.Discrepancy 18a.Discrepancy Indication Space ElQuantity ❑Type ElResidue ❑FailRejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1. 2. 3. 4. 20.Designated Facility Omer or Operator Certification of receipt of hazardous materials covered by the manifest except as nded in Item real ` PnntedRyped Name Signature Month Day Year r �ow a EP�Fonl87,0,g22,((3ev., p5) Previous editions am obsolete. DESIGNATED PACILITYTODESTINATIONSTA E(IFREQUIR D)