COMPLIANCE INFO_2021 - Laserfiche WebLink

Home Browse Search

Please print or type. P71Form Approved.OMB No.2050-0039 UNIFORM 14AZARDOU5 1,Generator IO Number 2.Page 1 of �3,Emergency Response Phone 4.Manifest Tracking Number WASTE MANIFEST 016210909 F L E 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) 9-,Cer>t5-;,Only #164 99 Cents Only#264 Ala # uf>-Lan .. Generators Phone: _ r 6.Transporter 1 Company Name U.S. PA ID Number . 1 CIPan Earth Specialty Waste Splutions 419SLA001 0924 7.Transporter''2 Company Name U_S,EPAID Number 8.Designated Faciiity,Namapnd,SrteAddress U.S.EPA ID Number Cis n ra)..,Enver ©rE�ental M.4 :LLC ,• :: 11855 White -Rack Road - '-Ati- FaCA I - Ragcho ..Ctr dcr;vat CA ,:;; •.. 95742.. .„ Faclity'sPhone:9 1-635 10980 CAD-98lf8 .4,L$, 3a. 9b,U.S.DOT Description(including Proper Shipping Name,Hazard Class,iD Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity V4fNol. ° .. 1JI4,1951a WjAst,eL Apro5ai:;s,. f,f;,_1aomablg,,.(eac p+.. INS:::: o exceeding 1 L capacity)] (Aerosols), 2,.1, : . ERG Z z. w s. 4. 14.Special Handling Instructions and—Additional lnformatior c. 15. GENERATORWOFFEROR'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, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national govemmental regulations-If export shipment and I am the Primary Exporter.I certify that the contents of this consignment.coriform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.17(a)(if i am a large quantity generator)or(b)(if f a a small quantity generator)is true. Generator's0feror's Printed/Typed Name f,, : S nature.() . f,:.a !�'�.; .ent ;,..On l.y r Month Day Year 16.International Shipments F ❑Import to U.S. ❑Export from U.S. Port of entrylexiC _- Transporter signature(for exports only)', Date leaving U.S.: W 17.Transporter Acknowledgment of Rec&pl of Materials LU Transporter 1 PnntedlTyped Name Sig lure Month Day Year Z Transporter 2 PnntedfTyped ame Signa a Month Day Year 1915 18.Discrepancy 18a.Discrepancy Indication Space ❑ Qeantity ❑Type ❑Residue ❑Partial Rejection Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) ��• U.S.EPA ID Number LM—a IftylyTiSo-� 3 42s ISIS Av& �/�/�'� 1 32 rai. aciiity's Phone. "'•"" �� Mo - y Year 18c.Signature o Itemate Foci Generator) 7 19.Hazardous W e R ort Management Method C&a.,codes for hazardous waste treatment,disposal,and recycling systems) !/ O 1 3. 4. 20.Designated Facility 0 r or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 183 Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM