Laserfiche WebLink
SSL <br /> Please, rjn r type.(Form cipsigned for use on elite(12-pitch)typewriter,): <br /> HAZARDOUS. 1`Generator ID Number Form Approved.OMB No 2050-0039 <br /> TE I(At IFEST' Peg 1 of 3.Em y p se 4.Manifest Tracking Number, <br /> Generator's Naive and'Mailing Address 71 SKS^� h fat Generator's Site Address(if different than mailing address). i7(� <br /> West StaPlord Rd Attu 0� 1 rah AfDESA <br /> Generators Phone, I "44 <br /> 6.T <br /> 7.Transporter 2 CompanyName TR I . <br /> U.S.EPA ID.Number <br /> B.Designated Facility Name and Site Address TV�VLEE OF CALIF �9I� U.S.EPA ID Number <br /> ETH AVE. <br /> 510-795-4400 N K A 94 60 <br /> Facility's t'hone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, <br /> HM and Packing Group(if any)) 10.Containers 11.Total <br /> 12.Unit 13,Waste Codes <br /> 1 : �'3 — h HAZARDOUS A T� L� ��� No: Type Quantity Wt.Nol. <br /> (USEP OIL)W <br /> TT G <br /> Z 2' <br /> 3. <br /> 4. <br /> 14.Spepal Handling Instructions and Additional Information" <br /> - <br /> TSDnl)?3�1 98 <br /> MTN, AS 17611 (SK TPI) <br /> "AGENT40R" By 9EN TO RETAIN LICENSED BUD CARRIFIRS AS NECES <br /> 15. GENSiiATOR'S/OFFEROR'S CERTIFICATION: I hSARY <br /> ereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name and ar <br /> marked and labeled/placarded,that the cont,antl are in all respects in propercondition for transport according to applicable international and national governments[regulations.If export Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledI mentme of Consent. a classified,he packaged,. <br /> 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 p rf shipment and I am the Primary <br /> Generators/Offero s Pnnted/Typed Name q ty generator)is true. <br /> �� y Sig ture <br /> r Month Day Year <br /> —� 16.International Shipments <br /> { <br /> F Import to U.S. ' <br /> Z Transporter signature(for exports only): ❑Export from U.S. , Port of entry/exit: <br /> W 17:Transportergckhowledgment of Receipt of Materials Date leaving U.S.: <br /> QT nspptt}r 1 y d a <br /> a- i11 f nature <br /> Month Day Year <br /> Q Transporter Printed/Typed Name <br /> L Signature <br /> Month Day Yea <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ;,. Quantity. ❑Type , <br /> M ❑Residue ❑Partial RejectionFuII l <br /> ❑ Rejection <br /> o, <br /> a <br /> 18b.Alternate Facility(orGenerator) Manifest Reference Number. s, <br /> i <br /> U S.EPA ID Number <br /> ' Facility's Phone:'' <br /> 18c.Signature ofAlternate Facility(or Generator) <br /> Month Day Year, <br /> 19:'11i4zardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. <br /> 2. <br /> ' 3 4. <br /> 20.Designated Facility 0 <br /> Pnntedff ed Name rator.Certification of receipt of hazardous materialscovered bythe manifest except as notgd in 18a <br /> Signature <br /> a Month Day Year <br /> arm7q 2 us editions are ob e. <br /> & � �' DESIGNATEn Gnru rTvr., -- -- <br />