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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
Scanner
SJGOV\gmartinez
Tags
EHD - Public
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SHIP# 233k'97977 <br /> 0 0 7 9 1 5 3 3 6 S K S <br /> Please print or type. Fcrm Aoproved.OMB No.2050-0039 <br /> ID Number 1 of pp!,.P" 4 <br /> 9`1 �'VIRn36 SKS <br /> UNIFORM HAZARDOUS 1.Generator ..'A RO 0 Q tAl <br /> WASTE MANIFEST <br /> 5.EeIn <br /> ,�erptor?.Name rd MailIT A Gen ress(if differert than mailing address) <br /> a It r em �B-1 d s., I n(7. <br /> CA 9S320–O!"00 <br /> Generator's Phone: <br /> 1. ( U.S.EPA ID Number <br /> QpRF�e�# 'TEMS INC <br /> ,repYL <br /> 7.Transporter 2 Company Name do U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address Lo i T–I'll L.E E IN S Y STE N U.b.tVA 1U Number <br /> T R, <br /> Si 7 <br /> S <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, i iG.Containers 11.Total 12.Un t 13.Waste Codes <br /> HM and Packing Group(if any)) N� o. Type Quantity Wt.Noi. <br /> tub W <br /> 1.1,1Uh1–RU'I`ZA IWA FAVOI A,�;I K I 'L J,il�i 1 <br /> 0 (AQUEGUS PARTS 64SHER SOLUTION) <br /> DIP, 100 <br /> L <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 11 Z5LJ I0 LIR LP.1 20 14 7777=777—u - <br /> reta ned by generator c-nmtfer�,, <br /> l-Ayl ir,it' a I t C.an ?�er tc.� add r -,ubstA tutv <br /> .1 _'i r addit-4-onAl t�ansparters on <br /> 15. GENERATOR'SIOIFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,arid 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 C sent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b) 1�f am a small quantity generator)is true. <br /> Generator's/Offerors Printed/Typed Name Sig re Month Day Year <br /> CzLf ILL <br /> –1 16.International Shipments <br /> 1:1 Import to U.S. Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> IX 17.Transporter Acknowledgment of Receipt of Materials <br /> LLI <br /> I.– Tgorter 1 Pnntedfll`yp�d Name Signatu Month Day Year <br /> w <br /> 0 0L1 )L <br /> CL Pcv)J –- ,.4 <br /> �E Tran3i��Printed/Typed Name ,,�gnature Month Day Year <br /> Le ez--- 1 <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space El Quantity 0 Type Residue Partial Rejection Full Rejection <br /> Manifest-Reference Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Facility's Phone: <br /> —7nth Clay Year <br /> LLJ 18c.Signature of Alternate Facility(or Generator) <br /> !R <br /> Z <br /> 52, 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LIJ 1 <br /> H 134 1 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifes��t snoted in Item 18a <br /> P Pid a e I liTure jJ M th Da Year <br /> AA <br /> EPA Fo Ve:1 7) Previous editions are obsol6td _-MAN1FESTSY§TEM <br /> J�,2� VINNATE ACHLITY TO EPA'i7e <br />
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