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Please print or type.(Form designed for use on elite(12-pitch)typewriter.f,1502193689-00i SC PPW 6li6J20i5 Farm Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest TrackiF1483-37:113 umber WASTE MANIFEST G A 10 0 0 2 8 4$ 2 5 r$oQ100831191 F L E 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) PAQ Inc DBA Rancho San Miguel 1409 S-Airoort War SAME Stockton,CA 95205 Generators Phone: (20919924463 6.Transporter i Company Name U.S.EPA ID Number Clean Harbors Environmental Services Inc M A D Q 3 9 S 2-2 2 5 0 7.Transporter 2 Compan Name U.S.EPA ID Number 5-" Z�2c) dr 372 8.Designated Facility Name and Site Address U.S.EPA ID Number Glean Harbors AraAoni iii ii600 North Aptus Road U T D 9 815 5 2-1'7 7` Grantsville.UT 84029 Facility's Phone: Wni ".8848100 ga, 9b.U.S.DOT Description(includirrg Proper 4 fpirrg"Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM any)) No_ Packing Group(if a 13.Waste Codes � No. Type Quantity Wt.Nol, age lip O 320A a r 2. Z ;w- tW7 ---— — — _:S ffiA ii GX190 PIG SOLID,N. 14.Si Handling Instructions and Additional Information 15. GtRekATOR'SIOFFEROR'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, markett ani Jabeledlplacarded,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 I�pcpter Fceftify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I t iIrtify that the waste minimization statement identified in 40 CFR 2 .27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is tru b Gene atgr sl erors Printed yped Na-!-;,,. ign o ear wr J 16.international Shipments F- ❑Import to U.S. ❑Export from U.S. Port of entrylexit: I ransporter signature for exports onl : — Date leaving U.S.: LAW 17,Transporter Acknowledgment of Receipt of Materials Transporter 1 Pdntedl-�Ip Signa CL r� QTransporter 2 Pd tedrIT Ipme Signature onth Day I Year 18.Discrepancy 18a.Discrepancy Indication Space Quantity Type ❑Residue ❑Partial Rejection ❑Full Rejection 18b,Alternate FacAity(or Generator) Manifest Reference Number. J U.S.EPA ID Number U a rl Fab li s Phone: w 18c.Signature of Alternate Facility(or Generator) Monlb Day Year Q Z 19.Haz ous Wase Roport Managoment Method Codes(a.,codes for hazardous waste treatment,disposal,a d recycling systems) w 4. 20 Designated Facility Owner or Operator:Certification of receipt of hazardous matenals covered by the manifest except a noted in Item 18a PrintediTyped N Signatu Month Day Year EPA Forrr47e00 Ai*,i�Wap{��"04AW966its for and will accept the waste the i ne S� f1*ILITY TO DESTINATION STATE(IF REQUIRED)