COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

i I, 1 Please print or type, (Form designed for use on elite (12-pitch) typewriter.) Form Approved. OMB No. 2050-0039 UNIFORM HAZARDOUS 1, Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Trucking Number ry pp pp �// WASTE MANIFEST COAL0004655€�`ea — ^�—�� 0 5 9 9 0155825 5 UUN1 K !' 5. Generator's Name and MallingAddress Generators alto Address (if different than mailing address) APt+I•s2<-RK UNI FORM AND CAREER APPAREL LLC 670 LONGE ST STOCKTO N, CA €5206 Generators Phcne:209-22W0105 - 6. Transporter 1 Company Name U.S. EPA ID Number PHILIP WEST INDUSTRIAL SERVICES CAR000177527 7. Transporter 2 Company Name U.S. EPAID Number B. Designated Facility Name and Site Address U.S. EPA ID Number CHEMICAL VVASTE MMeACEMENT INC CAT01000740117 M251 OLD SKYLINE ROAD Facility's Phone: 2.00-222=2904 re. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Centel am 11. Total 12. Unit 13. Waste Codes HM and Packing Group (ifany)) No. Type Quantity WUVol. 1. 0 NON RCRAHA HAZARDOUS AJAiiSTE, SOLI 1) 1 Moll I � V 49. 1 ! W 2. 3. b f 4. 14. Special Handling Instructions and Additional Information PROFI LE 9 CA508052 15. GENERATOR'S/OFFEROR'SCERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, hearken and labeled/placarded, and are in all respects in proper condition for transport according to applicable intemalionaland national governmental regulations, Nexpod shipment and l am the Primary Exporter, I cedlly.that the contents of this consignment conform to the terms of the allached EPAAcknowledgment of Consent. 1 certilythat the waste mli imizalion statement Idenfifled in 40 CFR 262.27(a) (If I am a large queerly generator) or (b) (if I am a small quantity ge is (me. GeneralorslO r dnted/iyp i '' Signature !� Month Day Year r 16. International Shipments F— ❑ Importfo U.S. ❑ Export from U.S. Port of entry/exit: Transporter signature (for exports only): Date leavi U,S.: � 17. TranspoderAcknowledgment of eipl of Materials o Transp r dattedlType a / + Signature Month Day Y ar a 7 M Tilinspeorkir 2 Pdnledfrypal Name Signature , V M nth Day Year h ,p 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue Petrl Rejection Full Rejection Manifest Reference Number: 181h. Altemate Facility (or Generator) U.S. EPA ID Number J U ra+. Facilitys Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year B y19, Hazardous Waste Report Management Method Codes (Le., codes for hazardous waste treatment, disposal, and recycling systems) ® 1. 2. 3, 4. c � 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted In Item 18a Pnnlectryped Name - Q Signature Month Day Year EPA Form 0700-22 (Rev. 3-0 re ions ecliglouns are obs fete, DEMO MATEDD FACILIYV 1 O DESTI]NAT ION STATE (IF REQUOR D)