Laserfiche WebLink
SSL &K SHIP# 23490658 Ilfll111fllllllllIflllflfflllll <br /> 1S 00 a 029020SKS <br /> Please print or type, Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1-Generator 10 Number 2.Page 1 of 3,Emergency Response Phone 4,Manit Tracking Number <br /> WASTE MANIFEST L �� 'itt�t r 1068029020 S K5 <br /> 5.Generator's Name and MaR4 Address Generators Site Address(if different than marling address) <br /> U"Heit1y # 4/19 � L <br /> 15879 S Harlan Rd <br /> LATHROP Cry 95330-9802 <br /> Generator's Phone: 209-234-1695 _- <br /> 6-Transport V Company Name SYSTEMS INC U.S.EPA Id Number T X 800008 1 20 5 <br /> 7-Transporter 2 Company Name U.S-EPA ID Number <br /> trt_EHN Iitih13I[JRS ENV SVC INC. MAD039322250 <br /> S.Designated Facility Name and Site Address CLEAN HARBORS URASSY mCuffl'A I N U.S.EPA lD Number <br /> 3 MILES EAST, 7 MILES NORTH KNOLLS EXIT 41, TIFF 1--86 <br /> KNOLLS , !1T 84083 <br /> 435 994-8915 UTD991301748 <br /> Facility's Phone: <br /> ga. 9b.U-S-DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11-Total 12.Unit I3-Waste Codes <br /> HM and P king Group(if any)) No, Type Quantity M./vol. <br /> 1 P fwjfo--ht:nH hHZHhLrUVf WHSTE: ;ai�I. D 1 DIS P 181 <br /> o (ABSORBENT AND OIL), �j;�►.- <br /> 2. <br /> LU <br /> 3. <br /> 4. <br /> 14,Special Handling Instructions and Additional information T5il,bM �� 105 U,116176 CSS: <br /> 24H EMEPCENCY#800--468-1760-CHISK/TFi-Contract retained by generator Linters agency actthomi / i <br /> on initial transvnrter to acid or slih,;titt.itp additinnal trancnnr}Qrw on upnp.-At-ryr' s behalf. <br /> 15. GEN ERATOR'SIOFFERDWS CERTIFICATION: I hereby declare that the contents of this consignment are fusty and accurately described above by the proper shipping name,and are classified,packaged, .�. <br /> marked and labelsdlptacarded,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 Ute 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)or(b)Sit!. small quantity generator)is true- <br /> Gensratoe s Prin*0 Name Signature Month Day Year <br /> N I I B In <br /> —j 16.International ShipmeMs <br /> r-- 1, ❑Import to U.S- ❑Export from U.S. Port of entrylexit: <br /> x Transporter signature(for exports only): Date leaving U.S.: <br /> E cc 17.Transporter Acknowledgment of PWoW of Materials <br /> Cr importer 1 OV PnrteaTyped N�J n <br /> 0. <br /> Le A <br /> Transpc Pr ntadTyped Name S gra tore , lNonlh Day Year <br /> 18-Disuepancy , <br /> 18a.Discrepancy Indication Space ❑ puar tity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejedon <br /> Manifest Reference Number, i <br /> r7 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> C.1 <br /> k Facials Phone: <br /> W 1 k.Signature o1 Alternate Facility(or Generator) Month Day Year r <br /> 2 <br /> 19-Hazardous Waste Report Management Method Codes Ii-e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. ► 2- 3. 4, { <br /> 20.Designated Facility pwner or Operator:Certification of recelpt of hazardous materials covered by the manifest except as noted in Item 18a" <br /> r <br /> ntedffyped Name Signature Month pay Year <br /> /�� ;�6v 1 L21!�� <br /> {� <br /> 'EPA Foran 87 (Rev. 2-1T) Pre s editions are obsolete. DE GNATE CILITY TO EPA's e-MANIFEST SYSTEM <br /> ,-.�, a ,� �. ,. � �• .-. ._ <br />