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Please print or type.(Form designed for use on elite(12-pitch)typewriter.61 i502i9368M0i SC PPW 6/16/20i5 Form Approved,OMB No.2050-0039 UNIFORM HAZARDOUS 1,Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Trackin Number WASTE MANIFEST :A L 0 Q a $4$ 2 fS0U14$3-371$ 0083 1191 FLE 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) PAQ Ino DBA Rancho San Miguel 1409 S.Airoort Wav gAMF Stockton-CA 95206 - - Generators Phone: (2091992-1463 6.Transporter 1 Company Name U.S.EPA ID Number Clean Harbors Environmental Services Inc MAD 0 3 9 3 2 2 2 5 0 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Clean Harbors Aragonite LLC 11600 North Antus Road - - Ct4�' r3 ��L(��L U T D 9 81 5 5 21 7 7 Grantsville.UT 84029 Facility's Phone: (41351984-103-1.00 ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantity wt./Vol, 04 r • ITfiNL:i,9. G 1),095 LU t Z 2.�uu ...�r�-r-n wu��en�r n�i mn r�ev+Aann u r W • • -•------- S -(QAMPI!@R.I69PFIGPAP!9La. 4-!16.PG I' HYP �--- r" P6 H 4. s 14.Special Handling Instructions and Additional Information � 91 M Ir 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,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shi ent and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. bf'� I certify that the waste minimization statement identified in 40 CFR 2 2.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is tru Generator's/Offeror's PrintedFTyped NaSigna Month DJ7 Q Year v J 16.International Shipments Z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature for exports only): Date leaving U.S.: w 17.Transporter Acknowledgment of Receipt of Materials ITransporter 1 Printed/TyZgnat Al- '00Ia , � v7 QTransporter 2 Printedi ped NameSignature Month Day ear 18.Discrepancy 18a.Discrepancy Indication Space El Quantity El Type El Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: Iz 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U Q r+ Facility's Phone: Lu 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z Cn 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LU 2` .iyJ 3. -H - 4. . f 20.Designated Facility Owner or Operator:Certification of receipt of haaza_rdo`us materials covered by the manifest except as noted in Item 18a Printedffyped Name Signature Month Day Year EPA Forrr-0iq��A&DiAasr� $u � sr�s��et�iglkits for and will accept the waste the-ener'A;riS'JWAfj6;ILITY TO DESTINATION STATE(IF REQUIRED)