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COMPLIANCE INFO_2021
Environmental Health - Public
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EHD Program Facility Records by Street Name
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2200 - Hazardous Waste Program
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PR0517881
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COMPLIANCE INFO_2021
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Entry Properties
Last modified
11/10/2021 11:42:57 AM
Creation date
9/13/2021 12:52:28 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2200 - Hazardous Waste Program
File Section
COMPLIANCE INFO
FileName_PostFix
2021
RECORD_ID
PR0517881
PE
2226
FACILITY_ID
FA0004254
FACILITY_NAME
ESCALON PREMIER BRANDS
STREET_NUMBER
1905
Direction
S
STREET_NAME
MCHENRY
STREET_TYPE
AVE
City
ESCALON
Zip
95320
APN
22514059
CURRENT_STATUS
01
SITE_LOCATION
1905 S MCHENRY AVE
P_LOCATION
06
P_DISTRICT
005
QC Status
Approved
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SJGOV\gmartinez
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EHD - Public
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�"�'�"� IIIIIIIIIIIIIIINNIIIHiIINilllllll <br /> SSL. SF' SHTPii 41y <br /> 0 0 6 9 5 3 3 0 3 S K 3 <br /> Please print or type. Form Approved.OMB No,2050.0039 <br /> UNIFORM HAZARDOUS 1,Generator ID Number 2.Page 1 of 3.Emer enc Response Ph a 4.Manifest Tracking Number <br /> r,AP! H0v39.}}- 1 1—: 0 4F -1�£0 006953303 SKS <br /> WASTE MANIFEST <br /> 5.Generators Name and Klailing Address Generator's Sit Address(if different than mailing address) <br /> Earalon Premier• R ard_ Tnc. <br /> 1905 Mchpnry A4'P <br /> F"CALFINCA 95.3EIV i '910 <br /> Generators Phone: 205..-5 <br /> 5 <br /> 2--%OsD I <br /> 6.Trans orter 1 Com any Name U.S.EPA ID Number <br /> S4�FFTY-- LEEN SYSTi"MS INC TXRt!n0Z `:=1T <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARROPS ENV PON`v1Ff%!Trd_ SVC INC. <br /> 8.Designated Facility Name and Site Address SAFETY—KL.EEN SYSTEMS., INC. U.S.EPA ID Number <br /> 610,00 83TH STREET <br /> SACRAMENTO F :58c$ <br /> Facility's Phone' <br /> ga 9b.U.S.DOT Descnption(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12,Unit 13.Waste Codes <br /> HM and Packing Group(if any)) <br /> o. Type Quantity Wt./Vol. <br /> 0 1 NON—RCRA HR-LIPIRi;CLIS WASTE LIQUID PM G 1.. 4 <br /> 0 '.AQUEO'?S PqR-rca WIPSH£"P: Vr,,IJTTON) b(V/ <br /> ~ PV <br /> w <br /> M 2. <br /> w <br /> (7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:SCA 7')1771 4"' �S 1 -'IA 14 CSG <br /> _ <br /> 10?p\ ',jOzj <br /> 24H EMERGENCY#800—«69-1760 CH 'SK>TFI—Coritykct re' ,)A.n2d rr-nestor r_rnfe�; .a 11 <br /> eFiry author-i .v <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and acIn <br /> slaty described above by the proper shipping name,and are classified,packaged, <br /> marked and Iaheledlplacarded,and are in all respects in proper condoon for transport according to aDPliceble intemalionand national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I cetlifyYhetthe convents of this consignment conform to the tens of the attached EPAAcknowledgment of Coant. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ita small quantity generator)is true. <br /> GenwalorslORerors Printetl/FyPed Name Signaluq` Mon Day Year <br /> 16.International Shipments <br /> r ❑Impodlo U.S. ❑Export from U.S. Pod of entry/exit: _ <br /> ? Transporter signature(far exports only): qate leaving U.S.: <br /> W 17.Trani Acknowledgment of Receipt of Materials <br /> T shDorter1 Printedrryped Name Signal Monfh Day Year <br /> m 1� <br /> d ( iCL- <br /> aTransposer 2 PnntedlTyped Name ignat �. .r Monty Da V <br /> F / <br /> 18.Discrepancy , <br /> 18a.Discrepancy Indication Space ❑ Ouanfi <br /> ty ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> r 186.Alternate Facility(or Generator) U.S.EPA ID Number <br /> v i <br /> W Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> z " I <br /> N <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p H141 2' 3, 4, <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 16e <br /> Signature Month -Da-y-7-earl <br /> EPA Form 8700-22(9071 -17) Previous editions are solete. <br /> 1 ) 1,49 41/15601--3 E (GNAT DFACILITY TO EPA's e-MANIFEST SYSTEM <br /> e _ <br />
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