Laserfiche WebLink
Please print or Noe. (Form desionerl fru use nn alita 119-nitrhl hmamuritar ) <br />r"mn^ppruvea. vmD rro. zfjW-uUJy <br />1. Generalor ID Number 2. P 1 of 3. Emergency Response Phone 4. Manifest Tracking N.M.UNIFORM HAZARDOUS rgency Res <br />WASTE MANIFEST CAL000332679 i 1-�-7$5,725 0 0 4863530 FLE <br />513engratofrs Nang tTd y abVVfbCMan LoOsOM LLC Generator's Site Address (il di event L1 mailing adtlress) <br />4199 Gibn tiw a. <br />Stodaon. CA 85M6 <br />Generatoes Phone: A 234^48'87 <br />6. Transporter I Company Name <br />U.S. EPA ID Number <br />Ad11AffGed Chorkai Transport kM (SV) CAR M70540 <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address C A' U.S. EPA ID Number <br />US Etda� N Inc G'tl <br />PPB =oloQT4Ac:NT <br />of 9,Hwy ,11 Mlles S Beatty HFA! THr Nii1330010000 <br />X000053 <br />Facilil/a Ptlone. <br />ga. <br />9b. U.S. DOT Oesc iption (indudumg Proper Shipping Name, Hazard Glass, ID Number, <br />10. Conta revs <br />11. Total <br />12. Uno <br />HM <br />and Packu,g Group (d arty)) <br />Quantity <br />Wt]Vol <br />13. Waste Codes <br />No. <br />Type <br />o <br />' NON RCIiA H.�ZAfiDOUS W. S <br />Diu <br />P <br />362 <br />I <br />( <br />z <br />2. <br />W <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />6"701; a 300 -52 died NMbK DoMnWt 07M <br />�6&S <br />56 <br />__GEHEoerno�mnccmcurne�s con .nnu. �.,,. .Wic <br />marked and labeled/placarded, and are in all respects in proper condition for trap � <br />sport according to applicable international and national govemmertai regulations, tl export shipment and I am the Primary <br />Exporter, f certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent, + <br />I cert y Ihat 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 gene s true. <br />ror's nn[ yped Name _gra re ay Year <br />Une <br />Z <br />Irt. tic ipments <br />trnpon to U.S. ❑ Export from U S. Part of <br />— <br />Transporter S nature for exports only): Date lewrig U.S.: <br />17. TransportarAcknowledgment of ReceiV of Materials <br />co <br />Tans er 1 t'ygiedfTypod Name gnat ear <br />A V1�rYt h�?� <br />Q3 o- <br />Q <br />Trans er 2 Pnntedrfyped Name measure Month ay Year <br />18. Discrepancy <br />18a. Discrepancy Indicaton Space Quantity ❑ Type ❑ Residue Partial Rejection ❑Full Rejection <br />Manifest Reference Number. <br />t8b. Alternate Facility (or Generator) <br />J <br />U.S. EPA ID Number <br />U <br />Q <br />tLFacili <br />w <br />s Phone: <br />18c. Signature of Altemate Facility (or Generator) <br />!R <br />Montle Day Year - <br />z <br />W19 <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste beabnent, disposal, and recycling systems) <br />0I <br />a <br />r <br />T <br />4. <br />20 Designated Facility Owner or Operator. Cartiffntion of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Printeda me Signature Moth Day Year <br />J -z— <br />FPA <br />�� (X ) - I a lj(;� <br />P— RRNL99 10-1_nS1 D --i-- —;.; ..,.... ..k....i_._ 512019— <br />_ DESIGNATED FACIL J Y TO DESTINATION STATE (IF REQUIRED) <br />