Laserfiche WebLink
Please print or type. Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS ' Ceneador ID Number 2.Pepe 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 012285179F L E <br /> 5.Generators Name and Mailing Address Generela's Sue Address(ddifferent Nan noting address) FOLD LABEL AT DOTTED <br /> Advanced Industrial Coatings LINE. AFFIX TO RIGHT <br /> 950 Industrial Dr SIDE OF HAZARDOUS <br /> Stockton, CA 95206 MATERIAL BILLS SO THAT <br /> Generators Phoria: TAB STICKS BUT, <br /> 6.Transporler 1 Company Name U.S.EPA IO Number ..Qftu rxn.,,.•n <br /> Advanced Chemical Transport Inc./DBA ACTENVIRO CAR000070540 <br /> 7_Transporter 2 Company Name U.S.EPA ID Number <br /> &nvYet3flt M&A-fAl3e-c ` 000 210737 <br /> 8.Desonated Fadliry Name and Site Address U.S.EPA ID Numbor <br /> Advanced Chemical Treatment <br /> 6133 Edith Blvd NE NMD002208627 <br /> Albuquerque NM 87107 <br /> Fadi' s Phona: rj <br /> ga. go.U.S.DOT Desofiptlon(iMutlNg Proper Stepping Name.Flared Class.10 Number. 10.Conlairrers <br /> HM ad Packing Gray(d�yll Tufa Ira.Unit 13.Waste Coles <br /> No. Type ou Ouanlity WWoI, <br /> U\1263,Waste Paint related material 3,PGII I 4 `A P 212 D001 f <br /> o X 9p1CQ <br /> w <br /> 1270 <br /> Z 2. <br /> w <br /> (7 <br /> 4 <br /> 14.Spedal Handling Instructions and Adnrmnrml lydomlafion Project Nffn1RCr 173827 Document#. D208412 <br /> 1)ERG#128, ACT86112ADA- If I1�ss�a <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are fully and accurately described above by On proper shipping name,and are classified packaged. <br /> marked and Iabel"pla rded,and are in all respect in proper cwdibon fobanspom according toapplicable inL=bonalar4 nabonal govemmemal mgul tons,d expot shipment and I am Ne Pnmary <br /> Exporter,I certify Nal the contents of this consignment conform to Has terms of the attached EPAAcknowledgment of Consent. <br /> I mgly that the waste minimiraBan stalem ilt identified h 40 CFR 26227(a)(d Ian a Inge quanfity generator)or(b)(RI am a small quantity gemma or)is true. <br /> GefamturslDflarWs Peinled7rypetl Name Signature Mon Day Year <br /> 16.Infertafioal Shpments <br /> ❑Import b U.S. ❑Expel From U.S. Port le ving xrt <br /> ? rarapata sgnaNre(kr exports only): Data leaving U.S.: <br /> W 17.Transporter Adrowledgment of Receipt of Materials <br /> CTransporter I Printed/Typed Name Signature Month Year <br /> O (/ <br /> 0 <br /> N <br /> 2 signature Month D Year <br /> O �gr <br /> .k 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Cheonthy ❑Type ❑Residue ❑Pa tal Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 1Bb.AOemafe Fa y(or Generator) USEPAID Number <br /> J <br /> U <br /> LL Fedlity6 Phone'. <br /> W tRc.SigrawreofAuamate Fadity(or Generator) Month Day Year <br /> a <br /> z <br /> H19.Hazardous Waste Report Management Method Cries(I.e..codes ler hazardous wrote treatment disposal.and recycling systema) <br /> 0 1, 4. <br /> Ig I <br /> 120. Fadliry Umeror Operator'.Certification of receipt of hazardous materials covered by Ne manifest except as road in Item i6a D <br /> 1Per Name ignature <br /> EPAForm8700-22(ReV.12-1f) P vmusmmnsareobsolete. DESIGNA 0 EPA'se MANIFEST SYSTEM <br />