Laserfiche WebLink
Form Approved. OMB No. 2050-0039 Please print or type. ( GENERATOR ) I UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Genera r IDeue3mbeor ,..3. I. s. _723 04 2 Page 1 of <br />I <br />3. Emergency Response Phone_ 6 <br />4g00 62.-c( 1,3 4. Manifest Tracking <br />021913641 <br />Number <br />JJK <br />5 Generator's Name and Mailing Address /c-d4a ex cveor, Generator's Site Address (if different than mailing address) <br />- ckokl ki -5-6-53' Hr)od w 7 TRACy, C. A '35377 HopktnS ed 4. S . j <br />7;eAcy, , CA cis---377 <br />Generator's Phone: 20 Ci R30 I <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />PATeio-i- 6Nvi10nni-e-At sex vic_e6 16A Do S g8667qq <br />7 Transporter 2 Company Name US. EPA ID Number <br />I <br />8. Designated Facility Narne and Site Address <br />Cra-Cbd (t OVe..74-1, rl U.S. EPA 10 Ntrnber <br />1é3° cA • 11 -Ph 51- Lo rtf ge.:kol-/, CA c t 0 8 13 CA D 0 2 gLiocto fq <br />Facility's Phone: SOO g -ii 47 251 I <br />ga. Pb. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unil 13. Waste Codes Fir,A and Packing Group Of any)) No. Type Quantity WI Not. <br />1. NoN PCRA IlAze,r-doo,s (,)"6-1---e- .Sond 001 DM 22° P -F23 /Tem <br />(o,'! y ctiy-4- debree ) 35'2 <br />2. <br />3, <br />4. <br />14. Special Harding Instructions and Additional information <br />Pr 6 PrCIP8( le qcf 835- prof; .11— <br />.,3-i:t o8— 22-0001s- '7.1113 -1 _> <br />15. GENERATOR'S/OFFER OR'S CERTIFICATION: thereby declare that the contents of this consignment are fully and accurately described above by the Roper shipping name, aid are classified, packaged, <br />marked and labeled/placarded, and am in all respects In proper condition for transport according to applicable International and national governmental regulations. If expo/ shipment and lam the Prknary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA AcFmowledgment of Consent <br />I certify that the waste minimization statement iden5fied In 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a I quantity generator) is true. <br />Generatoes/Offemr.'s Printed/Typed Name Signature Month Day Year <br />)(.. 5t" golgig oie- iaepiex 1A I I I (3122- _, <br />r— <br />16. International S pments Import to U.S. Export from U.S. Pori of entry/exit: <br />Transporter signature Oa exports only): Date leaving U.S.: <br />ce <br />I-- ce 0 a. r..9 <br />17. Transporter Acknowledgment of Receipt of Materials 'U Signature Transporter i PrintedITyped Name Month Day Year <br />ASh k‘,./1 /11001erillev141 1 1 1 1 13 1 22 <br />Transporter 2 Printed/Typed Name Signature Month Day Year <br />I I I I -4--- DESIGNATED FACILITY ---* - 18. Discrepancy <br />Discrepancy Indication Space LI Quantity LI Type Residue Partial Rejection Full Rejection <br />Manifest Reference Number: <br />Alternate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phones I <br />Signature of Alternate Facility (or Generator) Month Day Year <br />I I <br />19. Hazardous Waste Report Management Method Codes (i.e., codes tor hazardous waste treatment, disposal, and recycling systems) <br />1. <br />1/)q) <br />2. 3. 4. <br />20. Designated Facility Owner or Operator: Certilica ion of receipt of hazardous materials covered by the manifest except as nded in Item 18a <br />Printedff am Signature Month Day Year <br />..., <br />.2'2 -- e <br />I I i I I f P 'IAA I 1 r>1 •-- <br />s 0- EPA Form 8700- (Rev. 2-17) Previous editions are obsolete.