COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

'�+ :> . ; . Please print or, type: (Form designed 'for. use'ol♦!'eli (e (12-pitch) typewriter.) Form Approved. OMB No. 2050-00391 UNIFORM HAZARDOUS . 1 . Generator ID Number 2. Page 1 of 3. .Emergency Response Phone - 4. Manifest Tracking Number WASTE MANIFEST C A L 0 0 0 4 :2 8 3 8 . 1 (600) 424-9300 018529290 JJ K 5. Generator's Name and Mailing AddressGenerator's SiteAddress'(if different than mailing address) Y. . I ING STOC ;'Tt": CA, 95208 Generator's Phone: 20947 "181 6. Transporter 1 Company Name ` ; " U.S EPA ID Number 7. Transporter 2 Company Name U.S. EPA ID Number c WORLDWIDE REGUVERY SYSTEM INO. 0 A R 0 0 0 7. 7 5 4 2 2 8. Designated Facility Name and Site Address U.S. EPA ID Number YUMA YES LLC ?.730 E 131H ST ENVIRONMENTAL HEALTH AZ 85385 DEPARTMENT A7. R000515924 facility's Phone: 92 14+9628 ga. 9b. UIS. DO,TDescription (including Proper Shipping Name, Hazard Class, ID Number, 10.Containers 11 . Total 12. Unit 13. Waste Codes HM and Packing 'Group (if any)) R67 ;Type Quantity Wt.Nol, Ft F-I vv IF 0- 2 . ; Al OCT ? :JIu 4. By r - 14- SpeclabHandling.InslruclidhsLand,AddRional:Information:- - EM € RGENC CONIAOf CHEMTREC lw8w- 424-h#4W WotiS fhkM;INAI ;N�AERD�1911 �1�' 1r 1PRtFILE M 981 162623NRS-VAL891 PAPER FILTERS W * APPROPRIATE PPE EQUIPMENTIF' 15. GENERATOR'SIOFFEROR'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, 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 Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I 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. Generator'sf�i(ero s Printed7yped Name )( Signature a Month Day Year rrvrf/ 1... t �..fy_ It 16Jntern tionaI , ipments r ❑ Import to U.S. ❑ Export from U.S . Port of entry/exit: Z :Tradsporterslgnature (for exports only),&, W ,f OFFS Date leaving U.S.: W '17. Transporterkl nowleddment of Receipt of Materials I IF .Transporter 1 Pnntdd/ roed Name Signature Month Day Year b y t , t: IF Z Transjlbrter 2 Printe�llTyp'ed Nam ` . Signature, j Month . . Da Ye IF 18. Discrepancy 18a. Discrepancy Indication Space Quantity ❑ Type y ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J V ua. Facility's Phone. In 18c. Signature of Alternate Facility (or Generator) "" " "` _ r : :-Month Day': Year a Z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) LU oil I � � 2. 3. 4. MIFF 1 . 20. Designated.Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed(ryped Name Signature Month Day Year ILI 8700-22 Rev. 3 05 Previous editions are, obsolete. �,'. EPA ltrn ( ) DESIGNATED FACILITY TO GENERATOR �: _ + fIFI , - .