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CO0052987
Environmental Health - Public
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2500 – Emergency Response Program
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CO0052987
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Entry Properties
Last modified
7/11/2023 1:50:25 PM
Creation date
7/11/2023 1:08:37 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2500 – Emergency Response Program
RECORD_ID
CO0052987
PE
2546
STREET_NUMBER
1601
STREET_NAME
SCARBOROUGH
STREET_TYPE
DR
City
LODI
Zip
95240
APN
NEAR 06007044
ENTERED_DATE
11/17/2020 12:00:00 AM
SITE_LOCATION
1601 SCARBOROUGH DR
RECEIVED_DATE
11/17/2020 12:00:00 AM
P_LOCATION
02
P_DISTRICT
004
QC Status
Approved
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SJGOV\bmascaro
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EHD - Public
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Form Aoproved. OMB No. 2050-0039 <br />ricoac <br />A <br />II IL UI <br />UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number <br />CA L 0 0 0 1 9 4 4 7 1 <br />2. Page 1 of <br />1 <br />3. Emergency Response Phone <br />(800) 424-9300 <br />4. Manifest Tracking Number <br />020372734 JJK <br />Address Generators She Address (ti different than mailing address) Generators <br /> CErNRAL VALT.IN WASTE SERVICES INC CEN644 <br />P.O. BOX 241001 <br />LODI CA 95241 1333 E. TURNER RD ** SEE NOTES FO <br />209 333-5655 I LODI CA 95240 Generators Phone: <br />Transporter 1 Company Igarni U.S. EPA ID Number ‘s <br />WORLD OIL N <br />n <br />RONMENTAL SERVICES 1 CA D 0 2 8 2 7 7 0 3 6 <br />Transportieigireil U.S. EPA ID Number <br />RAO/S/0y Sli.‘`6A.A.r I ei4t,01X) P511 LI—. <br />Desiikaltri:Tsit,,,Narte,rd Site Address U.S. EPA ID Number <br />T C'''' LI"' 2730 E 13TH ST <br /> <br />YUMA AZ 85365 A Z R 0 0 0 5 1 5 9 2 4 <br /> <br />Facility's Phone: (928)344-9828 I <br />ga. 9b. U.S. DOT Description (Incktding Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit <br />HM aoff Paolffog GrouP Of any)) No. Type Quantity WI/Vol. 13. Waste Codes <br />cd o <br />NON-RCRA HAZARDOUS WASTE. SOUD (OILY SOLIDS) 352 <br />P I GENE <br /> <br />• <br /> <br />• <br />Special Handing Instructions and Additional Information <br />EMERGENCY CONTACT: CHEMTREC 1-800-424-9300 WOES TERMINAL CERES CS NAERG# 9131 : 171 * PROFILE # 9B1: <br />162623CEN644 OILY SOLIDS * *APPROPRIATE PPE EQUIPMENT t ).e. fl <br />GENERATORS/OFFERORS CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, ant are classified, packaged, <br />marked and labeted/piacarded, and am in all respects hi 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 EPAAckrowledgment of Consent <br />I certify that the waste minimization statement Identified in 40 CFR 26227(a) (if I am a large quantity generator) or (b) (III am a small quantity generator) is true. <br />GeneratorsPrintedrit Name Signatuce___________„1 Month Day Year <br />U •1 \ \ CCM 5 ---------_lg- <br />41Allt <br />p, <br />_i <br /> <br />International Shipm\ <br />f— Import to U.S. EExport U.S. Port of entry/exit <br />Transporter signature (for exports only): Date leaving U.S.: <br />ce tu 17. TransporterAcknowlecigrnent of Receipt of Materials TRANSPORTI Si Signature Trans p m l ,‘.......7......_, _2:ts_____4onth12_ Month Day 1 Year <br /> <br />ly e-41- evvi 2-___ I <br />Transporter 2Aled/Typed Ntkr;e6304,:f Signature Month Day Year <br />,14)I <br />A— <br />I I 17 174 4- DESIGNATED FACILITY --P 18. Discrepancy <br />Discrepancy indication Space Quantity Type Residue Partial Refection Full Rejection <br />Manifest Reference Number <br />Altemate Facility (or Generator) U.S. EPA ID Number <br />Facility's Phone: 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 for hazardous waste treatment, disposal, and recycling systems) <br />1. <br />14 1 (4 I <br />2. 3. 4. <br />29. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as ncted In barn 18a <br />Printed(Typed Name Signature <br />- LA WWI I *na CattflAc< <br />Month Day Year <br />1 01 I I C1174 <br />EPA Form 8700-22 (Rev. 12-17) Previous editions are obsolete. DESIGNATID..PACILITY TO EPAs
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