COMPLIANCE INFO_2020 - Laserfiche WebLink

Home Browse Search

Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Track- Number WASTE MANIFEST CAL000401855 1 8775772669 010 68274 F L E 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) Marshalls #M0381 Marshalls#M0381 2093650992 2429 West Kettlemen Lane 2429 West Kettlemen Lane Generator's Phone: Lodi, CA 95242 Lodi, CA 95242 6.Transporter 1 Company Name U.S.EPA ID Number Stericycle Specialty Waste Solutions Inc MNS000110924 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address 21st 'Century EM, LLC U.S.EPA ID Number 2095 Newlands Dr. East Fernley, NV 89408 Facility's Phone: 7755752760 NVD9808 5 338 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes X 1-UN1993, Waste Flammable liquids, n.o. s. 1 CF 00009 P 3311 D001 D035 (ALCOHOL, ACETONE), 3, PG II, ERG#1286nn� W 1 X 2-UN1950, Waste Aerosols 2. 1, ERG#126 1 CF 00001 P 331 D610111 > ) 3. s 4. 14.Special Handling Instructions and Additional Information 1. 102337(Flammable Liquids) 2. 102333(Aerosols, Flammable) 15. GENERATOR'S/OFFEROR'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 EPA Acknowledgment 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. Generator's/Off ror's Pdnted/Typed a Signaturen beha o X Month Day ear —116.International Shipm is02 KI-11 1 21 201 � Elim/port to U.S. ❑Export from U. .I Port of entry/exit: z Trans orter si nature for expo "nl Date leaving U.S.: W17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name ignature Month ay Year y Johnny Harper 02� 21201 Transporter 2 Printed Typed Name 11 Signr Month Day Year 18.Discrepancy �' � 18a.Discrepancy Indication Space. ❑ < Quantity ❑Type ❑Residue ❑Partial Rejection 1 ❑Full Rejection Manifest 18b.Alternate Facility(or Generator) Reference Number: U.S.EPA ID Number J U a a Facili 's Phone: w 18c.Signature of Alternate Facility(or Generator) Month Day Year a z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LLJ 1 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printedflypea Nfine Signature Month Day Year Q� -'" EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) 8700-22_112+3 CAL40000131 540024600 041046870 M PD022118 5D022118