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COWOHDPX6
Environmental Health - Public
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EHD Program Facility Records by Street Name
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2500 – Emergency Response Program
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COWOHDPX6
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Entry Properties
Last modified
11/19/2024 10:36:09 AM
Creation date
7/11/2023 1:43:42 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2500 – Emergency Response Program
RECORD_ID
COWOHDPX6
PE
2546
STREET_NUMBER
SB 1-5
Direction
N
STREET_NAME
I-5
STREET_TYPE
EXPY
City
STOCKTON
Zip
95209
APN
NEAR 06802001
ENTERED_DATE
12/31/2021 12:00:00 AM
SITE_LOCATION
1-5, EIGHT MILE INTERSECTION, STOCKTON
RECEIVED_DATE
12/31/2021 12:00:00 AM
P_LOCATION
01
P_DISTRICT
002
QC Status
Approved
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EHD - Public
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Please Duet or tvoe. Form Approved. OMB No. 2050-0039 GENERATOR UNIFORM HAZARDOUS <br />WASTE MANIFEST <br />1. Generator ID Number <br />LAC() 0 31(0 iiii9 <br />2. Page 1 of <br />/ <br />3. Emergency Response Phone <br />Pass - ye g 6 <br />4. Manifest Tracking Number <br />0 2 2 2 2 8 3 5 2 JJK <br />Generator's Name and <br />Sckr, eidel, <br />Gen-eraPageti <br />30 S . rina_kertaina <br />Mailing Address . Generator's Site Address (if different than mailing address) <br />tJal-i or 1-5 c,.)-- g AI, 1.20. <br />. 411 ; 3 ill 1 36 6 9 .z- Z000 I 4.1-ecktor, i co, 9,3- 2 05' <br />Transporter 1 Company Name U.S. EPA ID Number <br />An Coh MA /I A f I Q130 9`907j70,62' <br />Transporter 2 Company Name <br />tit. nt.v( vsci R 6 i-br <br />U.S. EPA ID Number <br />0 ,;( t_k_c_ I , 1 <br />Designated Facility Name and Site Address U.S. EPA ID Number <br />ONrct.i-er) , <br />i(c)30 N.1-1:1- cs.1-. Lor gecull, CA 90S/3 <br />Facility's Phone: (...0 . el 3 7.---A.Yq (1,5 1 CADoz-gtit0 GI of 9 <br />ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit Waste Codes <br />HM and and Packing Group lit any)) No. Type Quantity Wt.Nol. <br />1. <br />3, 5 2. <br />likj le ,Solicis(r, . S "al <br />szwari 1 ‘Dik4 ;io o P <br />2 <br />3 <br />tt <br />4 <br />---- ---- <br />14. Special Handling Instructions and Additional <br />EEG /7 1(1 y55) <br />Information <br />1109g9 <br />Jai4 30.)!2_ <br />15 GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, arzl 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 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) (if I am a small quantity generator) is true. <br />Generator's/Offerors Printed/Typed Name <br />Dr4C-AC-R- D p 440.el <br />1 Signa,ture ................„....../- Month Day Year <br />le)/ nickl-Ior,co 103 ID-1142- <br />_, <br />r.- <br />g <br />16. Intemational Shipments from U.S. Port of entry/exit: Import to U.S. Export <br />Transporter signature (for exports only) Dale leaving U.S.: <br />FK 17. Transporter Acknowledgment of Receipt of Materials . / fRANSPORTE Transporter 1 Printed/Typed Name/ Signature 7 I Day 1 Year <br />1A--1)(-)Li)(:)(/ . VI 1 <br />_D-te.iiieti) . Month Day Year <br />Transportec 2 rinted/Typed Name Signer- .i' <br />e. LI' Sit.ii 1,c:-`- I 0,23 16 ti I 21- I 4----- DESIGNATED FACILITY I" 18. Discrepancy <br />Discrepancy Indication Space Quantity Type Residue Partial Rejection IIII <br />Manifest Reference Number: <br />Full Rejection <br />Alternate 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 />H I t-I 1 <br />2. 3. 4. <br />20. Designated Facit'ly Owner or Operator: Certification of receipt of hazardous I naterials covered by the manifest except as ed in Item 181 <br />Printed/Typed Nqre <br />ASS I (CI <br />Signature <br />Lop-C1 -- I <br />Month Day year <br />1 lie <br />EPA Form Form 8700-22 (Rev. 12-17) Previous editions are obsolete.
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