Laserfiche WebLink
7[/q <br /> Please print or type. Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1 Generator IC Number1 of 3-EsIiJU F � tl�181Je 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL 040 379 505 2 Page afJU f 8�1 1 020202871 JJK <br /> 5.Generators Name and Mail Address Generators Site Address(if different than mailing address) <br /> ATTN.'NICOLPADAM 147 N.WILSON WAY <br /> P.D. BOX 512377 <br /> LOS ANGELES,CA 90051 STOCKTON. CA 95205 <br /> Generators Phone: 209 464-3829 <br /> 6 Transported CampanyName U.S.EPA ID Number <br /> EQ INDUSTRIA!.SERVICES MIK 435 642 742 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> BELT ICK INC, DBA TSMTCO MOD 095 038 998 <br /> 8.Designated Fmlity Name and Site Address US+ECOLOGY TULSA,INC. U.S.EPA ID Number <br /> 2700 South 25th West Avenue OKD 000 402 396 <br /> TULSA.OK 74107 <br /> Facilil Phone: (916)582-9595 <br /> ga 9h.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number. 10.Corlainers 11.Total 12.Unit <br /> HM and Packing Group(rtany)I 13.Waste Codes <br /> No. Type Ruantity Wl.Nol. <br /> Ell UN I ,1NrsteAINIl s, 2.1 (WT-Sp 11296),ERG#126 001 DF 0 019 <br /> 0 P 01101011 G►4033 <br /> W 2 RQ- UN 1993,Wrlsta Flamrmrbla liquids. n .s.(Avatone, 002 DF 00074 R 4001 L00 f?O1 <br /> Benzene),3,PGII, (RQ:DOI$),ERG#128 <br /> 331. <br /> X 3RCT,UN3265,~e CoffosWe b0d, basic,kiwi Iii n.o.s. 002 DF 00108 P D002 122 <br /> (Sodium Hydroxide,Potassium 1-iydroxide), 8,PGII,(RQ: <br /> D002),ERG#154 <br /> a. UN1 791,Vii1ade Hwoctiliforifte solLdions, 8,PGII,ERG#154 002 DF 00058 P D002 12 <br /> 14.S c�WH �Ir s c n# anditiOr�i 980P2�SF!# 1 SFHWUL-FEAWAABLE LIQUIDS 3. SFHWW 1 SFHV 04-C-ORROSIVE BAST=LIQUIDS& <br /> FS011 i1S 4.yFHWO61 SFHVM5-BLEACH i&BLEACH Sill CLEAN UPdABSORBANTS IT:14.1S.f3W71.111 <br /> 15. GENERATOR'SI IFFEROR'S CERTIFICATION: hereby declare that the contents of dais consignment are fully and accurately described above by the proper shipping name,and are classified,packaged. <br /> marked and labeledlplacarded,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 EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or jib)(ifl am a small quantity generator)is true. <br /> T lor's,'Offer&s PrintedlTyped Name tu Month Day Year <br /> L 07 2,51 19 <br /> 1 16.Intemadonal Shipments <br /> F— ❑Import to U.S. ❑Export from U.S. Po t entryiexit <br /> ? Trarspodersignature(forexportsonly) Dale leanngU.S.: <br /> LU 17.Transporler Acknowledgment of Receipt of Materials <br /> F— Transporter I PrintedfTyped Name <br /> O Month Day <br /> Year <br /> U3 07 25 19 <br /> A, Ail <br /> U3 Transporter 2 Prin ped Name Signature <br /> y ar <br /> h- <br /> 18.D.ep cy <br /> 18a.Discrepancy Indication Span ElI�I r <br /> Quantity El Type LJ Residue ❑Partial Rejection ❑Full Rejection <br /> } Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> LL Facility's Phone: <br /> W 18c Srgnalure ofAltemate Facility(or Generator) <br /> t Month Day Year <br /> Z <br /> N19.Hazardous Waste Report Management Mall Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU I <br /> H141 z. H141 3 H114 T <br /> H110 <br /> 20.Designated Facility Owner or Operatpr:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed,Typed Name Signature Month DayYo r <br /> EPA Farm 8704-22(Rev.12-17) Previous-edition are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />