Laserfiche WebLink
SSL SN: Si 22-17534614 111111111 III 111111 <br /> 0069529055 KS <br /> Please print or type. Form Approved.OMB No.2050A039 <br /> I.Generator ID Number 2.Page 1 of 3.Emep�ee�nccyY �spoge P C 4.Manifest Tracking Number �� <br /> UNIFORM HAZARDOUS CAR000039370 1 'j—}tuJer. s4htS— F•4'! <br /> WASTE MANIFEST <br /> 5.Generators Name and Mailing Address Generators Si Address(if different than mailing address) <br /> Escalon PreMier S:,ands Inc. <br /> 1905 Mchenry Ave CA 9S3tT-0000 <br /> FSCALON <br /> Generators Phone: " �9 `�Jr_' 'ac TV <br /> Iy�g U.S.EPA ID Number � 13000081205 <br /> s.Tr�gSppitgr�Y mKLYEFN SYSTEMS INC <br /> Z Transporter 2 Company Name U.S. D Number <br /> PA I <br /> 8.Designated Facility Name and Site Address SAFETY—KL EN SYSTEMS, INC, U.S.Ei1ATD Nuiffiber <br /> E1000 88TH STREET <br /> SACRAMENTO CAS+3rH <br /> 316-386-431?: .A2+0000R4517 <br /> Facility's Phone' <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 0.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) - `No. Type Quantity Wt.Nol. <br /> 1 NON--RCRA HA7AFrJOUS WASTE, LIQUID pl G 134 <br /> o (AQUEOUS PARTS WASHER SOLUTION) O/ _ D� I� <br /> � l� <br /> Z Z. <br /> w <br /> 3. <br /> 4. <br /> 14.Special Handling-nstiuctions and Additional Information TSD:SCA 79072468 ES12014 20194 C/S�G:21 <br /> 24H EMERGE..NCY#800-46,8-1760-CH/SK/TFI-Contract retailed by generator Co:ff�r� ae1Yc afl� i y <br /> on initial trans nrter to add or substitute additional trans Driers nn enera Dr' s behalf, <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and a rately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iaheledlplacanded,and are in atl respects in proper condition for transport according to applicable miasmatic al 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 EPA Acknowledgment of Ci insent. <br /> I certify that the waste minimization statement identified in 40 CFR 26227(a)(if I am a large quantity generator)or(b)fiff I am a small quantity generator)is true. <br /> Generatorstotemi's Printedr-yped Name Signature Month Day Year <br /> s�z - c 6 ► a� 19 <br /> 16.International Shipments <br /> ❑Import to U'S ❑Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving US.: <br /> K 17.TransporterAcknawledgmenl of Receipt of Materials <br /> ILLI <br /> Tr oder 1 Pd d(Typed Na Si Month Day Year <br /> G �i �4 lei <br /> z Transporter 2 Printedl7 ame greeters Martini Day Year <br /> r. l <br /> 2--q 114 <br /> ♦ 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑ sidue ❑Panial Rejection ❑Full Reject. <br /> ` Manif it Reference Number'. <br /> r 18b.Alternate Facility(or Generator) '< US.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone'. <br /> w 18c.Signature of Alternate Facility(or Generator) - Month Day Year <br /> Q <br /> 2 <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. HIit1 2. a. 4. <br /> 20.Designated reality Owner or Operator:CeNfiwtion of receipt of hazardous materials covered by the manifest except as noted in Item 1B <br /> 1 PdntedfTped Na signature Month Day/ Year <br /> y l / /D Z 9 . . ., �F <br /> EPA Form 8700-22 My.12-1Z) Previous editions area o"bs[ollete. DESIGNATE ACI TO EPA's e-MANIFEST SYS EM <br /> I) 14941/.5GOr'3 <br />