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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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99L VV 11111111111 IN 111111111111111111111111 <br /> 0 0 7 9 6 4 0 9 5 S K S <br /> Please print or type. INkfty Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number CAR000039370 2.Page 1 of 13.,E �y�t�s�ons�i r� 4.Manifest Tracking NNu/m�be(r�[� [ SKS WASTE MANIFEST 0 0 7 9 6 4 0 9 5 S KS <br /> 5.Generat s Name nd Mailin Addre Generators Site Address(if differen than mailing address) <br /> i^sca on F�refM brands Inc. <br /> 1905 Mchenry Ave <br /> ESCALON CA 95320-001')0 <br /> Generator's Phone: 209-552-6051 <br /> 6.t�r�FL7V -Wff meSYSTE11S INC U.S.EPA ID Number TXR000081;'O', <br /> 7aTranspEorte�r2 Compan Name U.S.EPA ID Number <br /> 8.Designated Facility Name andSite Address LIEEN SYSTEMS, INC. U.S.EPA ID Number <br /> 6000 88TH STREET <br /> SACRAMENTO . CA 95B28 <br /> 916-386-4913 CAOOOOO84517 <br /> Facility's Phone: <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> o (AQUEOUS FARTS BASHER SOLUTION) WA 12t7 <br /> z z. <br /> L <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 4 SO8 E9E912014 202127 CSG: 21 <br /> t rte', <br /> 24H EMERGENCY#800-468-1760-CH/SKITFI-Contract retained by generator s_1nfers agency autharit" <br /> on initial transporter to add or subs•titut,-- additional. transporters ongenerator 's behalf'. <br /> 15. GENERATOR'S/OFFEROR'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 labeled/placarded,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 conform to the terms 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)orA)(if I am a small quantity generator)is true. <br /> G ators/Offeror's Printed/Typed Narrig Si a re Month Day Year <br /> _. -v,A <br /> t <br /> 121 <br /> J 16.International Shipments <br /> El Import to U.S. El Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> LLJ <br /> Tr sporter 1 PrintedlTypMonth Day Year <br /> 0 1 -71 IPJ <br /> ns r 2 Printed/Typed Name Si re Month Da� Year <br /> 1-7Y ` <br /> 1 ucrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ElType <br /> ❑Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> N <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,J sposal,and recycling systems) <br /> LU 1. H141 2. 3. 4. <br /> 20.Desi nated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pri edlTyp e Sig to 21 lb <br /> Z <br /> )A_kA <br /> Efif q) Jo yey�L 17) Previous editions are obs D IGNATE:D F ILITY TO EPA's f,-MANIFEST SYSTEM <br />
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