Laserfiche WebLink
Please priest or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator 1D Number 12 13 2.Page 1 of 3.Emergency Response Phone 4,Manifest Tracking Number <br /> WASTE MANIFE3T J J K <br /> 5.Generator's Name and Mailing Address C- I rl r Generators Site Address(if differert than mafling address) <br /> CDLL c 5 149,CA 952io <br /> �T <br /> 209 47$-9971 <br /> Generators Phone: <br /> 6.Transpo00Kf&rfnpan�_W*'AR0NMENTAL SEfI1/CES u.S,E."-D--N'm X8 2 7 T 0 3$ <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> S.Designated Faclity Narne;and.Site Address U.S.EPA ID Number <br /> t3MPTDiii V 'CA 90222 ;:�;0$O 4 3 3$e <br /> Facility's Phone: (310)537-7100 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit 19.Waste Cedes <br /> HM and Packing Group(ri any)} No. Type Quantity Wt.Nol. <br /> O _ <br /> z 2. ... f.. <br /> W <br /> ca <br /> 'i-FS�1 AST-STREMA HAS SEEN - - <br /> =CR i-t_` r r OIAw!FIED <br /> `�C..r;�1�l,�rT,tEATf11FNTAT THE <br /> 3. "' Ell 71777—ORLE)ON <br /> RECYCLIiVO f ACiti T Y I;CCII'n-P T OIV: CALIFORNIA <br /> THIS FACILITY HAS THE NECESSARY P�-RPAf TS T <br /> RECEIVE YOUR WASTE STP.EAM AS <br /> 4. tiEn IS CAT 080D13352 <br /> 14.Special Handling Instructions and Additional Information <br /> SJ�Jv41 . s"-hjv"' *PROFILE <br /> RJFLe#uL:L OILY <br /> WATER* *APPROPRIATE PPE �f ? (� / 1 -5s <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately deseribed,above by the proper shfpping name,and are ciassitied,packaged, <br /> 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 <br /> Exporter,I cerfdy that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify thatthe waste mtnlmlzaSon statement identified in 40 CFR 262.27(a)[f I am a large quantify generator}or(b)(if I am a small quantity generator)is true. <br /> Generators/Offerors PrintetUTyed Name <br /> ,p S�mature w Month Day Year <br /> —1 16.Intematicnal Shipments --- <br /> ❑Import to U.S. ❑Export from U.S. Port of ehtrylexft. <br /> Transporter signature{for exports onl <br /> Yl� Date leaving U.S.: <br /> 17_Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> OTransporter 1 Printedffyped Name Signature >. Month Day Year. <br /> n <br /> rn <br /> Z <br /> Transporter 2 Printed/Typed Name Signature Month Day Year <br /> a <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El <br /> Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Aitemate Facility(or Generator) U.S.EPA ID Number <br /> C} <br /> LL Facility's Phone: <br /> LO 18cSig <br /> . nature ofARernate Facility(or Generator) Month Day Year <br /> a <br /> Z1 <br /> V519.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item186 <br /> PrintedlTyped Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />