COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

RECEIVED BY SJCEHD (EF) ON 8/22/19 Please print or type. Form Approved.OMB No.2050.0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST C A L 9 2 1 20604 6 1 LCL? 424-m Gema 020060134 JJ K 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) YSUPERSTORE INDUSTRIES(GROCERY DMSION 18888 MCKJNLEYAVF: LATHROP CA 85330 Generators Phone: 2 0 9 8 1 4 4 4 3 2 fi.Transporter 1 Company Name U.S.EPA ID Number FREMOUW ENVIRONMENTAL SERVICES INC C A R 0 0 0 1 7 1 0 1 7 7 Transporter 2 Company Name U.S.EPA ID Number E�eWORLDWIM RECOVERY SYSTEM INC C A R 0 0 0 1 7 5 4 2 2 a iJS��6W OGY INCiteAddress U.S.EPA ID Number HWY 9611MI S OF BFATT f BEATTY NV 89003 Facility's Phone: 775 563.2203 N V T 3 3 0 0 1 0 0 0 0 ga, 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 Gawp(if any)) No. Type Quantity W1Nol. 1-R6�4 Q UN32 .WASTE CORROSIVE LIQUID,ACIDIC,INORGANIC, D002 181 o N O.S.,(SULFURIC ACID,ABSORBENT}DOMJf IC' }� w 2.NON-RCRA HA AFtDUU WAS1 E,LIQUIDS(OILY WATER) C, 223 CD 3.NON-RCRAHAZARDOUS WASTE,SOLID(OILY DEBRIS, � � � 223 ABSORBENT) 4 CLEANERS) DOUS WSAflrSULID(HUUSEHULD1 14.Special Handling Instnrclions and Additional Information 1 XG)US0 013/708-12905 b111;'I=AddlAbSorbent ERG#164 2)US G 070131670.9061 a!y Water ERG 171 3)U;N�-�U 10'118300-86.39-O�ily Dees E G#171 4)US_G O70128300�i34 Cleanse, Household Sold CP ERG#171 '1\45-51-5 �5r1 3'55151 � ( X %E-', * HnIJnL Fitltl TO 13K 4 rRAiNEW AND 11513 PPI:. HR(;ontrwt FI 205907 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labefedfplacarded,and are in all respects in proper condition for transport according to applicable intemationaland national governmental regulations.11 export shipment and I am the Primary Exporter,l certify that the contents of this consignment conform to the terns of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 282.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)Is true. Gene ratpr sfOfleroes PrintedffyW Name lure ` Month Day Year I- Irk t: -e �- , I . 11t '�l ti 16.Intemational Shipments ❑Import to U.S ❑Export horn U.S Port of entry/exit: Transporter signature(forexports only)' 4-0 leaving U.S.. i 17.Transpo terAcluxWedgment of Receipt of Materials Transporter 1 Pnntedffyped Signature Mond Day Yer 5E Transporter 2 PrinteCyped Name Signature Month Day Year F-- 18,Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Altemate Facility(or Generator) U.S.EPA ID Number ul Facility's Phone' W 18c.Signature of Altemate Facility(or Generator) Month Day Year a z Vj14.Hazardous Waste Report Management Method Codes p.e.,codes for hazardous waste treatment,disposal,and recycling systema) LU 1. 2. 3 4 20.Designated Facility Ureter or Operator Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18a PrintedlTyped Name Signature Month Day Year EPA Form 8700.22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY