Laserfiche WebLink
SR_ 1111111111111111111101111111111111� <br /> Please print or type. (Form designed for use on elite 12 itch e 0 <br /> ! -P ) typwnter.) 063258903 K3 <br /> UNIFORM HAZARDOUS 1. Generator ID Number 2 Pa e t of E e Form Approved, OM13 No. 2050-0039 <br /> WASTE MANIFEST C(I1 . 01�1A tir :• t cY ns 4. Manl estTrac in N111 11 <br /> u tier . <br /> 5. Generators Name and MallingAddress0 5890 S �S <br /> C) tr` 15 ra_ Generators Site Address (ifdifferentthan mailing address) R� <br /> 1. 1OI P5 Avg <br /> STOrYTON <br /> CA 95215-402 `3 s <br /> Generators Phone: 210171 " 948- , 7E� 5t; <br /> 6 �t§ }, �rpQapyLbineSYSTEP1s INC <br /> U.S. EPA ID Number <br /> 7, Transporter 2CompanyName TXRot�4IMA j <br /> CLEAN HAf#;y-,RF l=l01R0Nmr. NTAI _ 34' f ' U.S. EPAIDNumber <br /> 11 WOMEN ..: rIVCw <br /> 8, Designated Facility Name and Site Address P1A3?�1 � rsa ;j <br /> CLf:AN t )ARAORS SPP Jf)Gt- <br /> 1 of: l 'At= RRYE`ISA ROPI i U.S. EPA ID Number <br /> 4013- 4 11 - 0% 2 SAN JC);iF.. r, <br /> Facility's Phone: <br /> 9a, <br /> 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, CAD059494 310 <br /> HM and Packing Group (if any)) 10. Containers 11 , Total 12. Unit <br /> 1'10imm ^!(?N RCF{t HAZARDOUS SCIL. IDSNo. Typo Quantity wt vol. 13. Waste Codes <br /> two ! I}EI? r Iti1 F'ETRI7f. FUM Gt ' 314 L . Ati fd7`F>� j DPI P <br /> LU 2' <br /> r <br /> Q <br /> 3. - W <br /> 4. <br /> 14. Special Handling Instructions andAdditional Information TSI) ; S TOVA <br /> 70/44 <br /> ®y <br /> Nr:' Et4ERCj P2Y # 1 .,.13t7-1Qt 468. 17Fo ( s N / SK l <br /> ACiTJ ( AS " ACEN7 - Ft )R " AY GEN TO RETAIN L. ICFNSED f SUB CARR IE Rti AS NECE� '7 <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 /> merited and rtify that <br /> the conte and are In all respects to proper condition for transport according to applicable intemaeonatand national governmental regulations. If export shipment and t am the Prima <br /> Emcporter, I Certify that the contents of this consignment conform 10 the farms of the attached EPAAdmowledgment of Cones t. P aged, <br /> ( certify that the wast minimization statement IdenBfied ' 40 CFR 262.27(8) (if I am a large quantity ry <br /> Generators/Offero s Pdn d/Typed me q ty 9enemlorj or {b) Qf l a a sm quantity gene ) is true. <br /> Signahr <br /> �L Month Day ye <br /> � 16. Intemefional ipments � f <br /> Transporter signature (for exports only): mPod to U.S. ❑ Export from U.S. <br /> Port entry/exit; <br /> w 17. Transporter Acknowledgment of Receipt of Materials D leaving U.S,: <br /> low Tran t <br /> pQ, <br /> I <br /> II <br /> Signature <br /> QTm o // Month Day Year <br /> Print /Typed Name <br /> 1E Signature J <br /> G>✓ Month pay Year <br /> 1811 111. Discrepancy <br /> 11 MINOR IIIII <br /> 1884 Discrepancy indication Space Quantity Type <br /> IIIIIIIILIIIII <br /> ❑ Residue El Partial <br /> ❑ Full Rejection <br /> Laii 18b. Altemate Facility (or Generator) Manifest Reference Number: <br /> V U.S. EPAIDNumber <br /> w FaciliVs Phone: <br /> 18c. Signature of Altemale Facility (ar Generator) <br /> d ' <br /> liii Oil <br /> z Month <br /> W 19. Hazardous Waste Report Management Method Codes (i.e., codes bay Year <br /> for hazardous waste treatment, disposal, and recycling systems) <br /> Q 1 2 <br /> 3. <br /> 4. <br /> 20. Designated Fa Owner Or Operator, rti8catio <br /> Printed/Type Na receipt of hazardous materials covered by the manifest ex t as n ed in Item 18a <br /> � <br /> Signature <br /> U t M h ay Y <br /> EPA Form 8700.22 (Re . 5) Previous editions a e e. <br /> DE NATED FACILI TO DESTINATION STATE (IF R U1 ED) <br />