Laserfiche WebLink
Please print or type, (Form designed for use on elite (12-pitch) typewriter.) = l+� Form Approved. OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1oF 3. Emergency Response Phone 4, Manifest Tracking NNumberrp p �/( <br /> WASTE MANIFEST . CA"10004056915 D c;22- ,si?_e-t. FDv 015895860 IOJM W <br /> 5. Generator's Name and MailingAddress Generatots SlteAddress (if different than mailing address) <br /> AR#JvkAr�K UN[ FtZ)RIO AIgD CAREER APPAF EL LLC- <br /> 7E79 LONGE ST <br /> STOCYN ON, CA HUM <br /> Generator's Phone:2M234-0105 <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> S. Designated Facility Name and Site Address U.S. EPA ID Number <br /> CHEP. ICAL 'At.-A.STE MAdAGEIME1491 INC CA. M0064-6117 <br /> 85751 OLD SKYLINE ROAD <br /> KETTLEMAN. Cts 934239 <br /> Facility's Phone: 3800-222'2904 <br /> 9a. 9b. U.S. DOT Description,(including Proper Shipping Name, Hazard Class, 10 Number, 10. Containers 11, Total 12. Unit 13, Waste Codes <br /> HM and Packing Group (if any)) No. Type Quantity WtNoi. <br /> a N10N RCRA. HA/�.l OLIS VVASTE, � � Chi 2p ® _S 'F <br /> U V34� <br /> Fit <br /> 2. <br /> 3. <br /> 4 <br /> 14. Special Handling Instructions and Additional Information <br /> PROFILE f& CA010G3852 <br /> 16, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by thepopershipping name, arc[ 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 EPAAcknowledgmenl of Consent. <br /> I certify that the waste minimization staleme t identified In 40 CFR 262,27(a) (if I am a large quantity generator) or (b) (iii am a small queenly gencrater) is true. <br /> GeneraloeslOfferot dribrifryp ne immune9 Month Day Year <br /> � l <br /> J 16. Intemaeonal Shipments <br /> "r - " ❑tmpag40 U.S. ❑ Export from U.S. Part of enlrylexil: <br /> z Transporter signature (for exfnc is only): , Date leaving U.S.: <br /> 17. TranspoderAcknowledgment of Receipt of Materials <br /> ad <br /> Tmnsp Prin edlr a ame Sig re Month Day Year <br /> a <br /> 6 Transpo 2Printed/rype Name, Signature Month Day Year <br /> h <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication SpaceQ fly ype no El Partial Rejection ❑ Full Rejection <br /> t� -L �sS �� v i ; 4 � � Lt�f� I 5S r /Q = <br /> Manifest Reference Number: <br /> 1Bb, Alternate Facility (or Generator) U.S. EPAID Number <br /> J <br /> U <br /> Facility's Phone: <br /> w like. Signature of Alternate Facility (or Generator) Month Day Year <br /> a <br /> z <br /> N19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> w q 2. <br /> t20. Designated Facility Owner Operator. Certification of receiptof surface materials covered by the manifest except a noted in II m 18a <br /> Punta and Name– -- __ _Month _ . Day—_ Year _ – <br /> EPA Form 8700-22 (Rev. 3-05) Previous e iti are obsolete. DE�BO(t9ATED G>?C6LOW M DENNf?TI M STATE (Ir L tMUM <br />