Laserfiche WebLink
Sri? SK SHIP# 227790509 <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number ,, 2.Page of 3.F�me�f�ge,��y Re qp a Phha��gq 4.Manifest Tracking Number SKS WASTE MANIFEST C(=11.OtZcf�115GQi�5 � .►�t3�10f��i�� 1 1V IAV <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> JC Trucking Inc <br /> 1415 W. Anderson St <br /> STOCKTON CA 95206-0000 <br /> Generator's Phone: 209-466-3282 <br /> 6.Tr psQpder],�pmppny I Q SYSTEMS INC U.S.EPA ID Number TX <br /> R01211088120 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENVIRONMENTAL SVC INC, MAI103932225121 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE U.S.EPA ID Number <br /> 1021 IBERRYESSR RAID <br /> SRN JOSE , CA �133 <br /> 408-441--QHS CA 59494310 <br /> Facility's Phone: <br /> ga 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 1. NONE NON RCRA HAZARDOUS WASTE SOLIDS, <br /> o (EMPY DRUMS)� <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD.-SJ 79370863 JC 10836 G,96.- <br /> 24H <br /> ;SS:S4H EMERSENCY#800-488-1760-CH/SK/TFI--Contract retained fay generator confers agency authority <br /> on initial transporter to add or substitute additional transporters an -generatorls behalf. <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked an4labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmentgl fec4u ations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 0 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity,generator)is ue. <br /> Generator's/Offeror's�rinted/Ty ed Name r Signature - Month Day Year <br /> +1 BC (1 k,,,. � <br /> J 1 16.International Shipments / <br /> p_ 1:1 Import to U.S. El Export from U.S. Port of e try/exi: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> uJ <br /> Transpo'�eer 1 Printed/Tyi5ed N'aame� / �/�y�>, Signature/ Month Day Year <br /> ZTransporter 2 Pri ed/Typed Name Signature Month Day Year <br /> H ' <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> Quantity ❑Type El Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 1. 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> I Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z1 <br /> v519.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> uJ 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardo s materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22 Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY <br /> 1)8553940/1793512 231W, 1- M'' 1 <br />