COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

'L SR SHIP# 22000` .�$ 0 0 5 5 9 5 9 3 6 S K S Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number `rf -f r�Y 2.Pagg 1 of 3t Emer�egcy R T-0nse Pttol�. 4.Manifest Tracking Number (� WASTE MANIFEST 1005595936 SKS 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) R8 Lab Robber Co, Inc. 8830 W Li.nne Rd )`RACY CA 95304-9109 GeneratorsPhone: 209-836-096S U.S.EPA ID Number 6.Trans 1 or ar Nye )XR000081*SOS i. I'-'- 7.Transporter 2 Company Name U.S. P mb 8.Designated Facility Name and Site Address 4,;a, :__T Y-S.;' __'- s _ 1 E.19', ;'f,t[ U.S.EPA ID Number fiVD r 8 I H' -Z-3 T REE SACRAMENTO , CA OI 5828 916--386-_4913 Facility's Phone: 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 1. NON-RCRA HAZARDOUS WASTEt LIQUID � _ o AQUEOUS `ARTS WASHER SOLUTION) ` 2� I Z 2. LU c7 3. 4. 14.Special Handling Instructions and Additional Information _,. ,•_F^ s _-- 'AFE"' s KLEEN} ,4 HR EMERGENCY 44 800-468-17600S �.,.., _i 66TH :A "AGENT-FOR." BY GEN TO RETAIN L.TCENSED SUP CA�'F2TE'h�S AS 4E.f.'��Sta. 15. GENERATOR'S/OFFEROR'S CERTIFICATION: 1 hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labelediplacarded,and are in all respects in proper condition for transport according to applicable intemat' ional 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 EPAAcknowledgme Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity genera (b)(if I am a s, II quantity generator)is true. Generator's/Offeror's Printed/Typed Name Signa e f Month Day Ye r J 16.International Shipments F ❑Import to U.S. ❑Export from U.S. Port of entry/exit: z Transporter signature(for exports only): Date leaving U. = 17.Transporter Acknowledgment of Receipt of Materials ~ s rter 1 Pdnted/Typed Name ature Month Day Year CL 11 110 Z Transproci d/Typed Name Sign Month Day Year m Vi - ll-= :�� 1, 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 181b.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 u, 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU 1. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except noted in Item Printed Name nature Month Day Year EPAFp",i37D0-22.(Rey.,3,05) Previous editions a�olete. 15ESIGNA ED FACILITY TO DESTINATION STATE(IF REQUIRED)