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GJ i50219360"0i SC PPW G/is/2015 <br /> Form Approved.OMB No.2050•0039 <br /> 2.Jge 1 of 1 4•Manlfest Tracking Number <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) X0`„'1 00830119 2 <br /> �� <br /> UNIFORM HAZARDOUS VAletlldl"2 g.4 8 2 3 <br /> WASTE MANIFEST Generators Site Address(if different than mailing address) <br /> s t4i �8�► it San MiAuel RAMF <br /> 1409 S.Airport Wav - - <br /> S odd0n;CA 95206 <br /> rHQ\44?_4 4CV1 <br /> GeneratofsPli U.S EPA ID Number <br /> s.Transporter 1 company Name MAD 0 3 9 3 2 2 2 5 0 <br /> Ciean Hall rs EmnronmentalServices Inc <br /> U.S. _.Number <br /> 7.Transporter 2 Comp Name <br /> L U.S EPA ID Number <br /> B.Designated Facility Name and Site Address 41111r n n n w c e n w -x'f <br /> Clean Harbors Aragonite LLC U r to a a <br /> 11600 NorthAntus Road <br /> r.rs, ;fie_UT f 4029 <br /> Facility's Phone: 3518 <br /> Containers 11.Total 12.Unit 13.Waste Codes <br /> 9a. 9b.U.S.DOT Descriptionto.Con <br /> (including Proper Shipping Name,Hazard Class,ID Number, Quantity Wt.Nol. <br /> HM and Packing Group(if any)) No. Type <br /> 1 NA3092.HAZARDOUS WASTE.LIQUID,N.O.S.,(BENZENE, / <�/) DQis <br /> o x GASOLINE),9,PG I11 6 343 <br /> D018 <br /> w 2'NA3077,HAZARDOUS WASTE.SOLID,N.OS.,(BENZENE. D — <br /> X GASOLINE).9.PG Ill 352 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructtons and Additional Infoamation <br /> ..1.CH991943a;!;�304- xfA-.r,1ERG 171 , [�14'I��J'�ME TAL <br /> 2.CHss1948�.yr�.wut 1'l1, ;lJ� n <br /> i,I=PA TU�9"NT <br /> ,. <br /> ad above by the proper shipping name,and are classified,packaged, <br /> 15. GENed and apeledi ERarde CERTIFICATION: I hereby declare that the con I I ` governmental regulations.If expZZ�e?"'31U61.4&�4 <br /> m the Primary <br /> marked and labeledlplacarded,and are in all respects in proper condition for tr. I Exporter,I certify that the contents of this consignment conform to the terms of anfity generator)is truW <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(i Year <br /> �. J`l <br /> Generatorsi eror's ed1T edName <br /> j 16.1ntemational Shipments Vs import to U.S. Ll Export from U.S. Port of entrylexit: _ <br /> Date leaving U.S.: <br /> Z <br /> Transporter signature for exports only): <br /> W 17.Transporter Acknowledgment of Receipt of Materials o a ear <br /> gnaw <br /> Transpo rintedll Na re <br /> J <br /> ignatum c�111 �y� ear <br /> QTransporter 2 fedff d ame <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space Residue ❑Partial Rejector Full Rejection <br /> ❑ Quantity �Type <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> 18b Alternate Facility(or Generator) <br /> J <br /> v <br /> Q <br /> x+ Facili 's Phone: Month Day Year <br /> w 18c.Signature of Alternate Facility(or Generator) <br /> Q <br /> Z <br /> SR19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 4 <br /> 1 H040 2 H040 s. <br /> 20 Designated Facility Owner or Operator:CertifIca11on of receipt of hazardous materials covered by the manifest except as noted in Item 188 Mon Day Year <br /> Printed Typed `( Signature000, <br /> )No—s) <br /> EPA Form 8700- 2(Rev.3-05) Previous editions are obsolete. j14 � iLITY TO DESTINATION STATE(IF REQUIRED) <br /> Clean Harbors has the appropriate permits for and will accept the waste the ne <br />