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BESAFE �N T 1 <br /> State Hazardous Waste '00, <br /> STATE AND FEDERAL LAW PROHIBITS IMPROPER DISPOSAL It. <br /> IF FOUND,CONTACT THE NEAREST POLICE OR PUBLIC SAFETY AUTHORITY,OR THE U.S. <br /> ENVIRONMENTAL PROTECTION AGENCY,OR THE APPROPRIATE STATE AGENCY. <br /> Generator Name: HD Supply Construction Supply,Ltd. <br /> HDS Location ID: CA304A REQUEST FOR BAGGED GOODS RECYCLING <br /> Address: 1166 S Wilson Way <br /> City,State,Zip: Stockton,CA,95205 B2h#:p2� Brench Address: Branch Manager•A¢,r <br /> EPA ID No.: CAR000167892 I I lrHo S.W r1.S o•1 W M DEA::brov red, 9s2Lul' 12o4a¢ ScN/.Ir�•ao <br /> Product Name: SOLE PAIL CLASSIC GRAY HARDENER LM SCOFIELD Date: dh <br /> HOS Profile Non-RCRA Hazardous Solid <br /> Name: Product Name White Cap 0,10.1 Container #of Comm,Condition of Product <br /> Part# Product Type Containers Imr4rna,eun,swNPWI <br /> Physical State: Solid IaroplweW Weight Itwe awn) <br /> Container/Zone: Yellow <br /> A7 LI&aYbraf so �,a 3 TeZ'J <br /> Waste Composition Non-RCRA Hazardous Waste Solid.Potentially Toxic to Aquatic are b• 141 422 ova< 6o)b 13Ao I <br /> and Hazards: Life. <br /> slkw lzs+ yga,vao Ndfn f <br /> Stan Dateof 29-JUN-20 <br /> Acm,mutaulaeon: slleo azf yff5zf5aJ SoiD 3 <br /> Quanfilyof Pieces 1 (iV, MoLToz MIK ZYTMMBp 831b <br /> for container/Skitl <br /> QJIC ZZTATVO W1 s <br /> DEA Signature: 4006l,51 AV 493C1So`IK SQIb —1 <br /> Comments ar res{",>r- 9sllb 2- <br /> Special <br /> Instructions: ,d*. Paz---AoD ;334c44 1416 7— <br /> HOS <br /> HDS Container#'100000129430- <br /> ?nP, 5#r 48317SeMw LOlb 3 <br /> II ° 3ulff 433RSJFSo CSib f <br /> III�II�I�IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII VIII III II III X�Mf�,76tn5, ZSS.$r-z�G �O,Ito 1 t'3 W <br /> HO Supply Proprietary&Wnfiden w <br /> KLEAFN <br /> / Indus <br /> rµ �eAn',pea pct NUNeEn <br /> 50 0ek CODn sane z,It 9 5 3 2 2 <br /> DenviCo rt uite2 <br /> (925)831-9802•(928)8J1-9183 FAX <br /> SAN DIEGO,CA RANCHO CUCAMONGA,CA H(AY)W)ARD,CA (POR)TLAND,O�IIBR TACOMA,WA <br /> (619)427-4711 ❑ (909)941-4076 (5701471-2 12100 ® (503)228-3965 ❑ (253)383-2168 <br /> STATEMENT OF WASTE DESIGNATION BILL TO PROJECT ADDRESS SHIP TO <br /> /. <br /> Representative samples were submitted,tested and reviewed in accordance with parameters set <br /> forth in 40 CFR part 261 for hazardous waste characterization and designation.According to 40 <br /> CFR part 262.11(2)and based on specific generator knowledge of this material,supporting <br /> documentation provided from analytical laboratory analysis,review of applicable Material Safety <br /> Data Sheets and other supporting documentation,the Generator has designated this material as; <br /> (check one) OUM NO. .SPECIAL INSTRUCTIONS �— " <br /> ORDER WE SHIPPINGDATE CUSTOMER ORDER NO. FOIL PROJI-CTNUMRER <br /> Non-RQRA1 ERM(25143.2) NOn.Hazardou8 PACKAGE T(1NSNNITS <br /> PRODUCTCODE SIZE . REM DESCRIPTION UNIT PRICE gMOUNT <br /> I certify that all information submitted in this Statement of Waste Designation and attached _ 11-77 <br /> documents are,to the best of my knowledge and belief,complete and accurate,and that all known or <br /> suspected hazards have been disclosed per California Title 22,pan 68260.200. <br /> SFO-19-239 STOCKTON <br /> Project Number Project Name <br /> HD SUPPLY 1166 SOUTH WILSON WAY,STOCKTON,CA 95205 NOM emMpuc Spentgeroslve tar Alemete Rew Materials Program ❑Exalu#W Rec "'"""IHSe N RCRA anent <br /> In gccpr4ence wltM1 CCR 2R,86281.241a)l2). AbroNve for Altamete Rew Metense Pmprom. <br /> Address CUSTOMER ASSUMES ALL RISKS AND LIABILITIES WHEN USING JUMBO BAGS <br /> Company ALL REUSED JUMBO GAGS MUST BE COMPLETELY TIED ANDD RIPS OR TEARS <br /> ROGER SCHIAFFINOIN <br /> ASSIST BRANCH MANAGER 11/8/19 REASON FOR EXCESS TIME: Ma fAG' put <br /> Print Name Title ate <br /> ��.rd Sig Rature TOTAL MILES DRIVEN: <br /> TOTAI.UNLOADING TIME: <br /> NOTES: / SCALE WEIGHT TARE WEIGHT NET WEIGHT <br /> THANK YOU FOR YOUR ORDERI <br /> RECEIVED BV:X �/ _DATE <br /> D:WwvNrII,VJeMNpISDwD.4x <br /> CUSTOMER <br /> ¢ ,. <br />