Laserfiche WebLink
Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST r .3 JJ K <br /> , <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> 0S Olt.C0.-STOCKTON 3616 NIAIN;y UR <br /> 1 IE'rT 3ACRAMENTO,CA 95631 <br /> Generator's <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> RAA';0'3 EN*i1IPONIViENTAL SERVICES INC. <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> 7-,Ni11RONNIENTA.L •3•f--^.'v10ES iNG• tCv.W4'4JL'. <br /> 1St r <br /> 1130r1TH RlIVERt RD. <br /> WEST SACkAOJFNTO,Cs, X91 <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 1. <br /> r`40N R:t".RA KA.a?A.RQ0 5; it AGTE SOLID ls'?It- DEURIS) c 3 <br /> Z 2. <br /> w <br /> CD3 <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> �1:�•1pF�Rr.�F3t..E#�"�.'�u'.�'/.S�er�;�sl~' $ � �� .`�...' ��� � I.�..e?y <br /> E.R. C0'N7RACT0R: kc4d!s''+ Fff--VIRON IENTAL <br /> HAPIOLERS: S'40tkg BE TRAINED AMC i l s,E APPROVED PPIC. <br /> 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, <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 this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> 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 /> Generatoes/Offeroes Printedrryped Name Signature Month Day Year <br /> 16.International Shipments <br /> i- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> z Transporter signature(for exports only): Date leaving U.S.: <br /> 13r- 17.TransporterAcknowledgment of Receipt of Materials <br /> Trans�rorter 1 Pdntedlfyp.d Name Signature Month Day Year <br /> .,r,, ;« <br /> M Transporter 2 Pdnted/Typed Name Signature ` e Month Day Year <br /> Q <br /> F <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantityyp <br /> ❑Type El Residue El Partial Rejection El Full Rejection ' <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> _J <br /> V <br /> u- Facilitys Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/r-y7ped Name Signature r 1 Month Day Year <br /> Ll �•.rC f �J,%iG.f l ul.:--•�C.: i/ /. f' r�,F", ✓�.ri <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY'S COPY <br />