Laserfiche WebLink
;d for use on elite (12 -pitch <br />Fedex Freight <br />4528 SOUTH HIMAY 99 FROMTAGR ROAD <br />Gene <br />6. Tra s r pang ame <br />1262)166. <br />1�7 3 <br />Form Approved. OMB No. 2050-0039 <br />2. Page 1 of 3. Emergerxy Response Phone 4. Manifest Tracking Number <br />8� 424-9300 007105125 JJ <br />Generators Site Address (if different than mailing address) <br />FSDB% FREIGHT (STK) <br />4528 SOUTH HIGHXAY 99 FROMTAGB ROAD <br />kM(!X'DR CA 95215 (289)466-2127 <br />I�IGUERAL ENVIROMMAL MGT, LLC DBA PSC EMVIROMM6MTAL SHRVICES <br />11855 RHITH ROCI ROAD' <br />FaciliWSPhone:..nemn nnnnnnx os eC7A9 MCI 9r:1-20211 <br />Iga_ �U..S. DOTDescription (including Proper Shipping Name, Hazard Class, ID Number, <br />HM n9 p (d any)) <br />1. MOM-RCRA HASARDOUS OASTS LIQUID (DETBRGUT) <br />W z. NON-RCRA HASARDOUS OASTH LIQUID (DKMG®T) <br />c' <br />3. <br />4. <br />10. Containers <br />11. Total <br />Quantity <br />12, Unit <br />WtAtj. <br />13, Waste Codes <br />No. <br />Type <br />001 <br />EI <br />00y7 <br />P <br />561 <br />0 o I <br />DH <br />0 ay <br />P <br />561 <br />14. Special Handling Instructions and Additional information i ) I Y,1 a Z > ( kri 0 <br />(1) FEFMOM ILIA -BB - PRO# 1976224574 (2) EUMORBILIQ-88 - PRO# 1913697922 <br />15. GENERATOR'SlOFFEROR'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 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 <br />Exporter, I certify that the contents of oris consignment conform to the terms of the attached EPAAdcnowledgment of Consent. <br />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. <br />Genera eslOfferoes PdntedITyped ame Signatu Month Day <br />— P in� OS o5' <br />j 16. International Ship nts <br />r— ❑ Import to U.S. ❑Export from U.S. Poentrylexit: <br />? Transporter signature (for exports only): Date leaving U.S.: <br />U 17. Transporter Acknowledgment of Receipt of Materials <br />�; Transporter t PrintedlTyped Name Signature Month Day 1 <br />C+l <br />a N A P=LNh.S N Call -d vl- ®s 10S /t} <br />QTransporter 2 PrintedfTyped Name�^ Signature Month . Day Year <br />IOU lig 12/— ,05 <br />19. Discieparky <br />18a. Discrepancy Indication Space ❑ Quantity, ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number. <br />18b. Altemate Facility (or Generator) U.S. EPA ID Number <br />ci <br />Factitys Phone. <br />W 18c. Signature of Alternate Facility (or Generator) Month Day Year <br />Z <br />H19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />11A 1.o <br />2. , L� t ` 3. 1 <br />4. <br />yj- q i <br />20. Designated "ity Owner or Operator. Certificationhazardous of receipt of hazrdt uuss materials covered by the manifest except as noted in Item 18a <br />Printed/Typed Name Signature nth pa Ye <br />r tV <br />:PA Form 8700-22 (Rev. -05) Previous editions are obsolete. DE&NATEDWCILrry TO DESTINATION STATE (IF REQUIRED) <br />10723.2187 <br />