Laserfiche WebLink
- SQL <br /> Please print or e, <br /> p type,_ 4 ` � ' Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page,1'of 3.Emergency RespOpse P,hoh� 7`1 <br /> nifest Tracking Number <br /> WASTE MANIFEST t'a4:t v �57:`r / 1! 0 c' �r,I C SKS 1" '1 tJ 0 I� <br /> S.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> E5celon Preuier Brandi Lrc. <br /> 1%5 Mchenry A%- <br /> ESCALON Cfh' 9Ea320-0t000 <br /> Generifofs Phone: c09�� 6051 <br /> 6.Transi eci Co §ny�� U.S.EPA ID Number + <br /> ,YLt_�N SYSTEMS INC T R®0ratb8120S <br /> 7.Vansporter 2 Company Name U.S.EPA ID Number <br /> CLEAN1{Ftl,i:: it�z� ENv SVS; INL;. M-101-14.1 ;=�:calll� <br /> 8.Designated Facility Name and Site Address Ci -"V I 5 0F'-',4 T 1_M T NGT ON' U.S.EPA ID Number <br /> I'a7 )FNNI S ,BEET <br /> WILMi,.c.i`Jf1 , CA 90744.. <br /> s 10-835-9998 ` CAD0A44i?993'i <br /> Fadlilys Phone: _ (` <br /> 9b.U.S.DOT Description(including Proper Shi m Name,H rd Pass,I¢ <br /> 9a. P� r 9Shipping 1 NWnber, 10.Containers 11.Total 12,Unit <br /> HM and Packing Group(d any)) 1 13.Waste Codes <br /> 1 No. Type Quaniily XNol. <br /> NON RC^Pr H(tARDOUS-WASTE LIQUIDS <br /> o ML W/ LESS Tl�a' N 10% WATER),-WAY <br /> 3. t <br /> 1 , <br /> 4. <br /> 14.S ei: Handljng Instru ons and Additional Infom,a:c:i T r + <br /> 24H EMERGENCY#800-468-1760-Cf 7TH-Contract retained bygenergta confers agency ju-chf)r. <br /> to PH nr ar1h0-i+-,r{:o AdHif;rnA'i f raan•:�.n.,F4r•� nn nnnc�r a r� n�ha +" <br /> 15. GENERATOWS/OFFEROR'S GERTIFICpTIQN: I hereby declarA that the contents of this consignment are fully and accuratvly�dakdbed above by the proper shipping name,and are classified,packaged, <br /> marked and l ed/placardedka"K a fr;&respects in proper conditon for transport according to appfcab(e Intern toyland national governmental regulations.If exporlshipment and I am the Primary <br /> Exporter,I ce ' that the contents of this consignment conform to the terms the attached E AAcimowkiebgment o nsent <br /> I certify ihiat tb ste minim¢adop s alement identified in 40 CFft 2V2.27(a))Tif I am a Targe uantily generator)or(b)(d I am a small quantity generator)is true. <br /> GetrratDNOffeioes Prinledfiyped Naiq� :' Signature r� Month Day Year <br /> 16.International Shipments <br /> F , mport to U.S. t ❑Export from U.S. Pbrt�epic rV t <br /> ? Transportet sigN!urs(for exports only): ( Date4ea4ingtS.: <br /> W- 17.Transporter Acknowledgment of Receipt of Materials <br /> OTransporter� ` 1 Printed/Typed Name 1 Z%� L signature) � r Month Day Year <br /> D (SII 4vud <br /> Transspwl5rr22 PrintedlTyped Name / 4. re Month Day Year <br /> 18:Discrepancy � �" `,Y •�'�� I /'t 1- <br /> s <br /> 18a.Discrepancy Indication Space F,Quantity `1 fzo'�- <br /> Ty ( Residueti D l0 Partial Rejection ❑Full RejectionManifest Referenncc <br /> ( e Number. <br /> 18b.Alternate Facility(or Generator) L U.S.EPA ID Number <br /> t <br /> LL Facility's Phone: I VJ <br /> W 18c.Signature ofAltemate Facility(or Generator) tianth Day Year <br /> a ' <br /> Z <br /> �. 19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste.treatment,disposal,and recycling systems) <br /> 2. 3. 4. <br /> 20.Designated Facility Owner of Operator.Certification of receipt of hazardous materials covered by the manifest except as noted In Item 1 Ba <br /> PrintedlTyped Name Signature j Month Day Year <br /> EPA Form 8700-22(Rev.12-1 Previous editions are.obsolete. DESIGNATED FACILITY/TO GENERATOR <br /> f7 681196/1877k <br />