COMPLIANCE INFO_PRE 2019 - Laserfiche WebLink

Home Browse Search

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 2.Page 1 of .3.Emergency Response Phone 4:Manifest racking Number WASTE MANIFEST C,4IA=128791 9 - s �5w-q00'244942,8 FELE 5.Generator's Name and Mailing Address Generators Site Addressj(if different than mailing address) Lu=Wce Reldl L Nfi RS#135. 400 LunING&PI do Jay MmOV 4=PACIFIC AVENUE Otl 4WO.5114 ST Chi,CA 9=7 ' Generators Phone: I 6.Transporter 1 Company 'me U.S.EPA ID Number AMERE1t EWIRCIMMEWAL SOLUTIONS 7 7.Transporter 2 CAxnpny Name U.S.EPA ID Number 8.Designated facility Name and Site Address U.S.EPA ID Number WASTE EXIMSS INC. 63M STAMU NI CRIVE MU 1123391 KMSM CITY,RAO 64120 Facilites Phone: g - - 9a. 9b.U.S.DOT Description(including-Proper Shipping Name,Hazard Class,ID Number. 10.Containers 11.Total 12.Unit Quantity Wtivol. 13.Waste Codes HM and Packing Group(if any)) (Isopropyl p �y _ No. Type P�n� X Waste RaQBIOP aEa s m r1lGm n.D.s. (Iso ro r n►w o tt Alcohol, ,4.1 ,UN9325.0� DF P x: 002. ' OHIO z 2.UJI 3. \ 4 14.Special Handling Instructions and Additional Information y - 1.)AWOval 0: 88:ERG 0133 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 classified,packaged, marked and labeledlplacarded,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.certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quanfity generator)or(b)(if 1 am a sqTql.quanfity gen )is true. Generato sl erors Print yped Name rgna / on ay ear J 16.International Shipments j. ❑Import to U.S. ❑Export from U.S. P�o try /exit: Transporter si nature for exports on : Date leaving U.S.: U 17.Transporter Acknowledgment of Receipt of Materials t2 Transporter 1 Printed/Typed Name ignatuort �a Year A I I S .� Q Tra Z PrintedlTyped Name ignat Month- ay 4A/d 11 IT -lo irbiscrepancy ° - ' 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection r Manifest Reference Number: F 18b.A temate Facility(or Generator) , ) U.S.EPA ID Number ., . Facilitys Phone: W 18c.Signature of Altemate Facility(or Generator) Month Day Year 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) C 1. � 2. - z 3. 4. 4 \ 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials cevered,by the mandest except as noted in Item 18a Printedffyped Name . ` ha I t o nth ay year VN EPA Form 8700.�(Rev.3-05) Previous editions are obsolete. '� �.1 DESIGNATED FACILITY TO GENERATOR STATE(IF REQUIRED) 10503.1884 -