COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

Please tint or . Form designed for use on elite(12-pitch)typewriter) Form Approved.OMB No.2050-0039 P h'Pe ( 9 ( P ) YP ) Pp UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST I CARM278318 12 18775772669 . I 011434267 F L E 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) :Dollar General #13592 Dollar General#13592 2098@08820 310 W DR MARTIN LUTHER KING JR - 310 W DR MARTIN LUTHER KING JR Generator's Phone. STOCKTON, CA 95206-1763 STOCKTON, CA 95206-1763 6. ransportar 1 Company Name U.S EPA ID Number Steric cle Specialty Waste Solutions Inc MNS000110924 7.Transporter 2 Company Name U S.EPA ID Number �•P� ��G� ��/�— � ii%OJ/ C��O�vjr�yy� 8.Designated Facility Name and Site Address 21st Century EMN, LLC U.S.EPA ID Number 2095 Newlands Dr. East Fernley, NV . 89408 Facility's Phone- 7755752760 NYD980895338 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. X 1UN19509 Waste Aerosols, flammable 2. 1, ER8#126 1 BA 00034 P 331 D001 0 W X 2UN1791, Waste Hypochlorite Solutions 8, PG 1 DF 00089 P 12E D002 III, ERG#154 X3UN1.057, Waste.Lighters, 2. 1,- DOT—SP 13179, 1 BA 00001 P 331 D001 ERG#115 X 4UN1993, Waste Flammable liquids, n..o.s.. 1 CF 00004 P 331 D001 (Alcohol), 3, PG II, ERG#128 14,Special Handling Instructions and Additional Information 1..PKG-DF:110541(Pero s o 1 s) 2. 110517(B 1 each, Liquid) 3.PKG—CF: 110543(Lighters),,. 4.110518(Flannable Liquids — Loosepack) 15. GERERATORVOIFFEROR'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. rator s nn y me gnature Month ay ear 1 081 081 201 16 Inte lona Shipments H ❑Import to U.S. ❑Ex rt lrorm U.S. Pof of entrylexit: Z Transporter signature(for exports only): Date leaving U.S.: IX 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 PrintedfFyped Name rnon ay Year 0. Isidro Martinez .. 08� 08� 201 Z Transporter Printedflyped Name .— Signature 1Mol I ay� Year Z 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number V I LL Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Z U519.Hazardous Waste Report Management Method Codes(i.a.,codes for hazardous waste treatment,disposal,and recycling systems) 1 r Q F20, 12,VVA\ I3. Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a V � I Sign T I Mth I Day EPA Form 8700-22(Rev-3-05) Previous editions are obsolete. DE�IGNA ED—'-'FACIL Y TO DESTINATION STATE(IF' -REQUIRED) anal,-22 12x3 CAL20072032 541053278 041159956 M PDOB0818 SD080818