Laserfiche WebLink
I ; <br /> SK fa P'•# 2'42T,51 1244 <br /> Pieas"tinit.nr,type.(Form designed for:ti4or1 eiitel(12•piich)typewrlter.)` Form Approved.OMB No,20500039 <br /> Sit41FORMi HAZARDQU5 t.Gbneralor l0 um or 2.Page i of 3 EmergencyResponse Phone. 4,Manifest Tracking Number j c <br /> WASTE MANIFEST CAL000 4i a 1.0 �. ��-8 t0�-468-�1760 93 <br /> t a+' <br /> 5.'Ganeraiors Name and Mailing Address Genera S' dd (if different than mailing adtlressj <br /> �i ;~a Air StstLxs IC <br /> a1� 87th St <br /> SACRAMENTOCA, CA 9581 <br /> Generator's Phone; 9.16✓ 444 -25� <br /> 6.Traits over 1 Co n Name U:S.BPA 10'Number <br /> rYr.� �L EN SYSTEMSy INC. s I TXROt OOS1205 <br /> 7.Transporter 2ComganyNama U:S:EPAIDNumber <br /> CLEAN HARBORS ENVT'R I M ISVCS INC <br /> 8,Designated Facility Name.and biteAddre'ss LEAN HAR81OR� `.SAN JOSE U.S.EPA ID Number <br /> 1021 OERRYESSA ROAD <br /> SAN JOSE CA 5518.3 <br /> 40 CAD059494310 <br /> Facility's Phone: <br /> ga, 9b.U.S.DOT Descdpiton(including Prop r Shipping Name,Hazard Class,ID Number, 1o.Containere 11.Total 12.Unit 13,Waste Codes <br /> HM and Picking Group(if any)) No. Type Quantity Wt,/Vol. <br /> o NON RCRA fl.ZARDOUS WASTE SOLI. j � !)M R 223 <br /> (Dt{ s, r t i� M YDROC�at� r�rass <br /> UJ <br /> 3. <br /> 4. <br /> EE <br /> 14 Specjal%rib.lidliRq.lnttfuctions and Addiilonal In(orm lion. TSD v S-1 727671387 C133793, CSe <br /> ;'4. HR t 3 OEh1 Y #1,-�8L�0—� 68-17180 (SK I TF D <br /> AJ)r.H AS ++ � . u c' i1~ 0$'UM." RRnpt:V <br /> 15 GENERATOR'810FF.EROR'S CERTiFICATI N`there. declare that the contents of this consignment ara)tuliy and accurotelydescdbed,abovebytheproper.shipp!pq name,and are classified;packaped, <br /> markod and labeiptl/placarded,and are in ail fesp�cls in proper condition fortransportaccoiding io apptica6(s intemagonptand notional,governmental regulations;if export shipment and f am ihePnmary , <br /> Exporter,Iorlifytfietthe contentsofthis.cop gn enlconformta{ha termsoftheattachedEPAAcknowledpraentof'Consent: <br /> ntfy that tho waste.minlmiiotion stalemen irJen'fiedln.40-CFR 262:27(a)(it I am a large quantity.generator)or.(b)(if(am a small quantity generator)Is true, <br /> enar rs1 rinleopedAtime signature Monlh Day Year' <br /> � '16 Inlemafiona manis • <br /> ^�Import't Us ❑Pxpori from U.S. Part of entry/exit: <br /> Transporter signature(tor oiipons only): gatb lea41ng U.S.:. <br /> 17.TranspafterAcknowledgmenibfReceiplo(Mate als <br /> Tramp* PrinladfTypedNerria slgle, Month Day ' r <br /> 0 <br /> d Transporter 2.Printeallyped Name } 1 ' Signature ,,. -''. Month Day Yee <br /> 1. <br /> 18,Discrepancy <br /> 188:Discrepancy Indication Space E Qua Sly ❑Type ❑Residua El Portal Rejection F1Fu((Rejegtlon <br /> Manifest Reference Number: <br /> i8b.Alternate Facility(or Generator) U.S,EPA ID Number <br /> ri Facility s Phone: <br /> 180.Sighatuie of Alternate Facility lorGeneralcr) Month ay Year <br /> I r <br /> Z4 R�. .. <br /> �—y 191Hazardous.Wa@te: ego Management. elhod Cod s(i.e.,codes forhat5Ytlous waste treatment,disposal,.and recycling systems) <br /> n 1. 2, J. d <br /> 20.DeSignat d Facility Owner or by (ator:Ctirlificl eon 0 recelpt.o hazardous materials cov ed by the manifest except. dad in Ife ,' <br /> Printed yp Name I Signature r Month Day Yle'"ar� <br /> (. a ✓rl <br /> EPA <br /> 1ro m 8�0.22(Rev.0� Previous editions bsolete O, I 7kD t=ACII IY�TO GENERATOR <br />