Laserfiche WebLink
HAZARDOUS 1.Generator ID Number Form Approved.OMB No.2050-0039 <br /> {� ksT 2.Page 1 of est Tracktn Number <br /> E MANIFf=STS g <br /> g�r to�i.Name ar�d Mailingg,&ddre s em. , SKS <br /> CF tYt gat,> ` GeneratorsSite Address(if differentthanm ilio address) <br /> 185@RAC West Stanford Rd Atm Samuel Mohenr�y lA���A rata n rd Rd <br /> TRACY CA 95377 <br /> Generators Phone: g` � *-5.374 Attn Lta�t"er Sabo <br /> 6.Tr _ - TiRCY CA7""9 <br /> SYS� � 708 <br /> U.S.EPA ID Number <br /> TX W080�1205 <br /> 7.Transporter 2 Company Name <br /> U,S.EPA ID Number <br /> 8.Designated�actlity,Name and Site Address <br /> 6880 SMITH AVCS Cf�LTFL# IA � U.S:EPAIONumber - <br /> 510-795--4400 NEWARK � CA 9 <br /> Facility's Phone: <br /> CAD 887418 <br /> 9a, 9b.U.S.DOT Description(including per Shipping Name,Hazard Class,ID Number, .• <br /> HM and Packing Group(if any)) 10.Containers 11.Total 12.Unit <br /> O 1. NON—R`iED "AZAN���� WASTES LIQUID No. ,Type Quantity Wt.Nol. 13.Waste Codes <br /> TT <br /> iz 2. <br /> 0 <br /> i <br /> 3. <br /> 4. � <br /> 14.Special Handling Instructions and Additional Information $ � <br /> AD 0198 <br /> 4H ERGENCY 6 46 1' 60-CH/SK/TFI-Conty` rt retained r �spar��o� � n��r� �or '"itxaltransPorti to add or Substitute additxOnal O � auth'ritar ^ wnr � <br /> y <br /> 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, <br /> 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 <br /> Exporter,I certify,that the contents of this consignment conform to the terms of the attached EPAAcknowledgment 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(b)(if I am a small quantity generator)is true. <br /> Generators/Of erors Prmted/Typed Name <br /> Eric—�t A � Signa re � Month Day Y• Year <br /> 16.International Shipments .,.1 <br /> ❑Y) Import to U.S. ! t <br /> Transporter signature(for exports onl ❑Export from U.S. Port of entry/exit: <br /> 17.Transporter Acknowledgment of Receipt of Materials Date leaving U.S.: <br /> Trains er 1 Pd ted/Typed Nam 3 <br /> L J ! #!'f Sign re <br /> ( _ /. ._ �,"� M ih D y, Year <br /> Iransporter2 Print d/Typed Name t - 1 <br /> Signatures <br /> Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space d <br /> ❑ Quantity ❑Type <br /> ❑Residue ❑Partial Rejection <br /> ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number: <br /> z <br /> t i U.S.EPA ID Number <br /> Facility's Phone: �. <br /> 18c.Signature of Alternate Facility(or Generator) <br /> Month Day Year <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for haze <br /> Irdous waste treatment,disposal,and recycling systems) <br /> . 2 <br /> 3. 4 <br /> 0.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> riot—yped Name <br /> Signature <br /> Month ay .Y a <br /> Oil <br /> i ZZ't Y17� Previous.ediiio s are obsolete. <br /> Ea f GENERATOR'S INITIAL COPY <br />