Laserfiche WebLink
SSL SK SHIP# 229212578 liiiiiiiiii iiiiiiii <br /> 0077816848S ss <br /> Please print or type. Form Approved.OM�L.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number CAR000039370 2'P eJ of 3.EmeJggpyy Resgo)ise P1hgiR� <.Manifest Tracking Number <br /> WASTES Name and ]I 1 GrerO 4tstl Ifa007181884 SKS <br /> 5.Generator's Name and Mailing cress Generators Site Address(if different than mailing address) Iw <br /> Escalon Premier Brands Inc. <br /> 1905 Mchenry Ave <br /> ESCALON CA 95320-0000 <br /> Generators Phone: 209-552-6051 <br /> 6.T'9ff`t,rt.ContLAn9LV SYSTEMS INC U.S.EPA ID Number TXR000081205 <br /> 7.Transporter�2 YComtppannyy Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MAD039322250 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> Facility's Phone: SAN JOSE , CA 95133 <br /> 408-441-0962 CAD059494310 <br /> 9a 9b.U.S.DOT Desorptim(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quandy Wt.Nol. <br /> X 1 NA3082, HAZARDOUS WASTE, LIQUID, mpoP <br /> D011 135 <br /> N.0.S. , (SILVER), 9, PG III ©co DF <br /> a64o <br /> = 2. LNON RCRA HAZARDOUS WASTE SOLIDS, DM P 352 <br /> 1-1 <br /> ARS RBENTS CONTAMINATED WITH OIL), O I <br /> 3. <br /> 4. <br /> T-. <br /> 14.Special Handling Instructions and Additional Information TSD:SJ 80849537 612 <br /> 1)ERG#171 <br /> 24H EMERO NCY#800-468-1760—CH/SKITFI—Contract retai ed by generator confers a ency authori y <br /> on initial transporter o , <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accuritely described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeledlplacarded,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 canfonm to the tens of the attached EPA Acknowledgment 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 /> General me Print drryped Na ccc,,, Signature Month Day Year <br /> 11 ; c. / t <br /> 119 <br /> J IF Ince na hipme 1 �� b <br /> p_ ❑Impo U.S. ❑Ezpod from U.S. Port of entry/aut: <br /> = Transporter signature(for exports only): Date leaving U.S.: <br /> W <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> K T porteddntedlTyp Name Signatl Month Day Year <br /> IL S <br /> 2Prin Name , re Month� Day Year <br /> Ih Vx <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indiafion Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection <br /> I ❑Full Rejection <br /> Manifest Reference Number: <br /> 181b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> CW3 18c.Signature of Alternate Facility(or Generator) <br /> F Month Day Year <br /> Q <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 01. O !anO 2 9. 4. <br /> I20.Designated Facility Owner or Operator:Certification of receipt of h Mous materials covered by the manifest excO as noted ii Ias <br /> Pnnted/Typed Name - Signatu Mal D� Ye <br /> EPA Form 8700-22(Rev.12-17 Previous editions are obsolete. D GNAT AGILITY TO EPA's e-MANIFEST SYSTEM <br /> 1)$6$1155/187984 ^2)8684282/1$79 9 <br />