Laserfiche WebLink
I � Form Approved,OMB No.2050-0039 <br />;lease prini-or type. 11, 4.Manifest Tracking Number LE <br /> 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone <br /> UNIFORM HAZARDOUS (877) 577—�= �" <br /> WASTE MANIFEST -af=14 �' ' Generators SiteAddress(if differentthan mailing address) <br /> 5.Generator's Name and Mailing Address <br /> arshalls$�10- iE! <br /> Marshalls #M0381 `4`9 gest I',ettlest:an l ane <br /> (209) 3F,5-09924E3 West I',ettlefnen Lorre Lodi, CA 95'42 <br /> Generator's Phone: <br /> Lad i CA 3524 U.S.EPA ID Number <br /> 6.Transporter 1 Company Name ;N�_,001u umber <br /> ` f�9c4 <br /> Stpric cle S eclalt Waste rjalrltlan5 Inc U.S.EPAIDN <br /> 7.Transporter 2 Company Name <br /> U.S.EPA ID Number <br /> v <br /> 8.Designated Facilit Name and Site Address General Environmental Mgt, LLC <br /> 11855 White Rack Road <br /> Rancho Cordova, CA 95742 CAD980884leM- <br /> Facility's Phone: 0 9 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, No Type Quantity Wt.Nol. <br /> 9a. _ , ,., ~31 I7LA�1 <br /> HM and Packing Group(if any)) DF �;�,0;;t.;�, `rte <br /> 1LIN135Q�, Waste Aerosols 1, ERG#126 <br /> 0 <br /> a <br /> Z 2. <br /> W <br /> 3. <br /> 4. <br /> 1�Dr-333�flerosols, Flammable) <br /> 14.Special Handling Instructions ano,dditional Inform1. <br /> ation 2 <br /> r condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> 15. GENERATOR'S CERTIFICATION: I herebyrdoeelare that the contents of this consignment are fully and accurately described above by the proper shipping name,arcf are classified,Packaged, <br /> marked and labelediplacarded,and are in all respects In proper q erator is true. <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. er X Month Day Year <br /> certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity Signatuneratore Q(b)(if e d ial qua f ) , 7 2L <br /> L <br /> Gen tor'sloff r' ri edlT e <br /> Po f entry/exit: <br /> 16.Intern Tonal Shi ents Import to U.S. ❑Export from U.S. a leavi <br /> Z Transporter signature(for exports only): Year <br /> Month Day <br /> W 17.Transporter Acknowledgment of Receipt of Materials Signature A;' y ;_ <br /> Transporter 1 Printed Typed Nlll e <br /> Month Day Year <br /> a ..t. r}t.fi• Signal re <br /> ZTransporter 2 Printed/Typed Name <br /> 18.DiscrepancyEl Type ❑Residue <br /> ❑Partial Rejection Dull Rejection <br /> 18a.Discrepancy Indication Space El Quantity <br /> Manifest Reference Number. U.S.EPA ID Number <br /> F 1 Bb.Alternate Facility(or Generator) <br /> V Month Day <br /> Year <br /> tai Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) <br /> a <br /> Z 4. <br /> 0 19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems <br /> 2. <br /> 0 1. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifestnat except cept as noted in Item 1 a <br /> Month Day Year <br /> PrintedlTyped Name <br /> DESI ED FACILITY TO EPA's e-MANIFEST SYSTEM <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. �'j}Q`07 SD020700 <br /> Irl <br />