Laserfiche WebLink
Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page of 3. mefg .cy RQspOse Phofrt3V1 4,Manifest Number <br /> WASTE MANIFEST tiii �t �4YY>" 11 ff � 0> S KS <br /> 5.Generatots Name and Mailing Address Generators Site Address(if different than mailing address) <br /> r,i y Iii;hart <br /> 31. 95 Fid <br /> TRACY CA 95304-7111-94 <br /> Generator's Phone: 510-23,5-7970, <br /> 6.Tra[l Qn� £o ny�Ea e ,,E 4 r U.S.EPA IP Number T i r� 5 <br /> STE2 NC <br /> 7.Transporter 2 Company Name U.S.EPA ID Number _ <br /> CLEAN HARBORS' ENV SVC 1K. MAD0w932250 <br /> 8.Designated Facility Name and Site Address CLEAMPRBORSCSF�1 i T TONU 11-LOW U.S.EPA ID Number <br /> �t <br /> BUTTONWILLOW CA 93206 <br /> Facility's Phone: <br /> ga. 9b.U.S.DOT Des&pfion(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and <br /> h7Packing <br /> ^Group(if <br /> hany)) l�IL 1s y t��� 7 ft � t� No. ;.., Type f Quantity .WtJVal, <br /> 1. �t�ti�FN& NOM �4CRA 9'iA �i!"iDOU S WdAi?T� SJOUIDS, DMI <br /> LY <br /> Z 2. <br /> to <br /> C`] <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Aeffonal Information T,19D p B L <br /> r Ptalilvi by r--0q'ce-ti agegC:y a=at11,3r1 M <br /> vin initial tr•'answrter it) add ter 5r.Fbstittti;e atidi-tir:nal al•, rltnerakW s behalf. <br /> 15. GENERATOR'SIOFFEROR'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 labeledlplacarded,and are in all respects in proper condition far transport according to applicable international and.Vatonal governmental regulations.If export shipment and I am the Primary <br /> Exporter,l certify that the contents of this consignment conform to the terms of the attached EPAAcknowtedgment of Consent.i ' <br /> I certify that the waste minimizafion statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if1 am a(small quanlily generator)is true. <br /> Generator'alOfferoer,PrintedlTypedName Signature t j; Month Day Year <br /> 16.International Shipments <br /> i= ❑Import to U.S. ❑Export from U.S. Pori of entrylexit: <br /> Transporter signature(far exports only): Date leaving U.S.: <br /> at 17.Transporter Acknowledgment of Receipt of Materiats <br /> u, <br /> Transporter 1 PrintedfTyptd Narr a Signature f'" r Month Day Year <br /> CL <br /> z Transporter2Pnmedllyp90Name ISignat6fe ' _ Month Day /Year <br /> r` <br /> J <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type r ❑Residue ❑Pariial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 16b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> Lam+ Facility's Phone: <br /> ilia 18c.Signature efXtemate Facility(or Generator) Month Day Year <br /> a <br /> 2 19.Hazardous Waste Report Management Method Codes(I.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1. 2. 3. 4, <br /> 20.Designated Facility Owner or Operator:Cert fication of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PrintedlTyped Name Signature Month Day Year <br /> EPA Form 8700,22kRev.12-17 Previous editions are obsolete. GENERATOR'S INITIAL COPY <br />