Laserfiche WebLink
Please print or type- 7Ji905013126 SIC Il 3/12/2019 Form Approved.0 M B No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 or 3.Emergency Response Phone 4 Manifest Tracking Number <br /> WASTE MANIFEST IC-AROOOOS9656 (800)483-37118 014 216 5 3 7 F L E <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address} <br /> Quest Industries Llc <br /> 2518 Hoeing Way AME <br /> Stockton. d9 ?4��314g <br /> Generators Phone' <br /> 6 Transporter 1 Company Name U.S.EPA ID Number <br /> Clean Harbors Environmental Services,Inc. MAD 0 3 9 3 2 2 2 5 0 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8 Designated Facility Name and Site Address U.S.EPA ID Number <br /> Clean Harbors Buttonwillow LLC <br /> 2500 West Lokern Road GAD 9 8 0 6 7 5 2 7 6 <br /> ButtomNillow_CA 93206 <br /> Facility's Phone, fIl 62_6200 <br /> 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 0-Conlamers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13 Waste Codes <br /> No Type Quanbty Wt.1V01 <br /> X 1'NON-RCRA HAZAF2DOU•S WASTE,SOLI DS,(EORO.SI LIGATE <br /> FR#T.ZINCOXIDE) � C►��1 <br /> w20161 V' <br /> f -L-�✓ <br /> Ct <br /> Z 2 <br /> w <br /> 3. <br /> 4. <br /> 1q.Sp l HaanTtlimn nssactions and Additional Information <br /> P; <br /> UtnOr!r$ Or. irliil31 iransrorier to add or ssUbSfiitlie additional lrarisporterc Oft eneral0�& beftalf for u osss of rain Contract retained <br /> gi°n y.con conifers aoenco <br /> 15. GENERATORVOFFEll CERTIFICATION: I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name.and are classified,packaged, <br /> marked and IabeleWplararded,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 Pnmary <br /> Ex iter.I certify thal the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent- <br /> 1 that the waste minimization statement identified in 40 CFR 262.27(a)(if i am a large quantity generator)or(b/fl am a small ardily ge rator)is true, <br /> Gen atdrsloffe�er's PnntedlTyped Name I Signature r Month Day Year <br /> }��C^h ;rGtn'1 �� ; e( <br /> 1 4/4 4Z <br /> fntemational Shipmen - <br /> 11 Import to U.S. ❑Export from U, . Port of entrylexit. <br /> ansponer signature(for exports only): Date ieavin <br /> W Transporter Ack ent of Receip Materials <br /> ransp r 1 Pnnte y S' nature <br /> �p � � �� Month D Year <br /> IE Transpo - Printed typed Name Signature Month Day Year <br /> w <br /> 8.Discrepancy <br /> 'ea.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> F 18b.Alternate Facility(or Generator) US FPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> 18c.Signature of Alternate Facility(or Generatar) <br /> Q <br /> "low Day Year <br /> Z <br /> f 9 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> w • <br /> Hi3.2 2 3. 4 <br /> 20.Designated Facility Owner or Gperator'Certification of receipt of hazardous matenals covered by the manifest except as noted in Item 18a <br /> PrintedlTypedName Signature <br /> Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. o ,q u + <br /> Clean Harbors has the appropriate permits for and will accept the waste thegeneragESis NA F-D FACILITY TO EPA's e-MANIFEST SYSTEM <br />