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PPW 2/24/M5 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter:) I Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C A L Q 0 0 2 8$92 3 s.. (800) 483,3713 <br /> fl <br /> :�-) <br /> 04 FLE <br /> SG S 0097 <br /> .Z MqAn t8i rfng address) <br /> 1409 S.Airpoft <br /> - SAME <br /> Stockton.CA�20b <br /> Generator's Phone: (2091 5'3.'x.'146 3 <br /> 6.Transporter t Company Name U.S.EPA ID Number' <br /> Clean Vwbors Envirartrl a ai Sergi,I m I -MAD639322.250 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> B.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Clean Harbors A iriize LLC U T D 9 8 3�5 B 21�� <br /> iiC200 Haf h Aptus Raat3 <br /> Gram:UT t&W s9 <br /> Facility's Phone: (43511933-91 00 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total _ 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 1'MA3077.8t47�S'WA.M.90UD.N.O.S.,(BENZEI-QE, Wig 352 f <br /> Z 2. <br /> LU <br /> 0 <br /> 3. <br /> 4 <br /> 14.Special Handling Instructions and Additional Information E. <br /> I._CHS 919!5. ,LRIS 3.?.1 _. .. .,:. l 1= i.�-s_s <br /> Y, <br /> 15. GENERATORVOFFEROR'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, <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 EPAAcknowledgment of Consent. <br /> 1.certify 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(ryped Nameigna w <br /> Mlont ay Year <br /> � 16 — _ <br /> H ❑Import to U.S ❑Export from U.5/ Port of entry/exit: <br /> . International Ship mems — — _ <br /> z Transporter signature(for exports only) Date leaving U.S.: <br /> wL 17'Transporter AcknowledgmentofRec6ot;ofMaterials <br /> Transporter i Printed/Typed Name t Signature 1 Month Day Year <br /> zTransporter 2'Print��ped'Name Signature Month Day. Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑ j ❑Full Rejection <br /> ty ❑Type ❑Residue Partial Reaction <br /> Manifest Reference Number:` <br /> 19b Alternate Facility(or Generator) U.S.EPA ID Number <br /> Q <br /> FaCilitYS4Phone <br /> W 18c,Signature of Alternate Facility(or Generator), Month Day Year <br /> a <br /> z <br /> y' 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> w 1. 2. ... <br /> Ht} <br /> 20:Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pnnted/Typed;N m C `� Signature ' ,r Month . Day f Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. - DESIGNATED FACILITY TO GENERATOR <br /> i <br /> ,lit HaAof 4.-a the.. Imits f4 and*It io tept 0*!oq'I� Pte• <br />