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' •QTS) . 0'33 ,4 .`64 ) <br /> 0 <br /> Pte a pfintor pe.(Form designed for use on elite 12 rich Gj 15OA-1 01 .S PPYJ G/46l2015. <br /> ty ( y )typevmter Form Approved.OMB No.205HO39 <br /> UNIFORM HAZARDOUS t Generator ID Number 2.Page 1 of 13.rEmergein Response Phone <.ManNest TracMing Number <br /> WASTE MANIFEST CAL 0 0 0 3$4 2 9 tB)OOy 493-3719 ®� 763558.. ' FLE <br /> S.1pM1y Nypa�od fail' dry Generator's Site Address-Adifferent tlran mailin adtlress - <br /> tl°vdid Ah1S AD',ISF1 PdIDY7 0 b2i70{),�IC ,Ea ( 9 ) <br /> 620 SminlrTCb2aok�v lam gAMa,�: <br /> LOCH.CA 96240 <br /> Generator's Phone: (2 091 9 9244 6 3 '. . , <br /> 6.Transporter 1 Company Name _ U.S.EPA ID Number <br /> ClUmn Hwtan Envgronenon¢al SeMc2s Ina <br /> LIA0039392250 <br /> 7.Tmnspoder2 _ U.S. AIDNum ,r . <br /> 5 ) <br /> B.Designated Faali a dSite Address thli.EPAID umber <br /> Mmn Horbars AraAcirrib LLC U T D S 9 5 5 4 1 7 7 <br /> 11600 Ranh Aiii Road <br /> Grmmvi&e.UT 94029 <br /> Fadity's Phone: (4351894.8100 <br /> 92 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.ContaNers 11.Total 12.Unit 73.Waste Codes <br /> HM and Palling Group(daM)) 1, No. Type Quantity WWoI. <br /> 0 n <br /> K <br /> W <br /> w 2' U�?YBa5.�7AE�C9LEL9L15.�JAgBC.fi7.O:S., d� `0001 <br /> '� tt (CAMPHOR.ISOPROPA80LL 4.1.(RG 81 ® ®F 10 0 <br /> 331 <br /> a. UWi479,'0ASTEON104ZINGSMID.0.02..QCALCIUCA 0001 . <br /> M �INLORITIESOLID-SODBIBMHYF�WLOWESOLIDI.5.1. � N� '17o <br /> 14.Special Handling Instructions and Additional Information <br /> 2.QH1007399'1$�,v NI p� 133 . .'•t= <br /> 3.CH1'00,7412=fa'rt6,�nap2EFtG <br /> 15.' GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this mtxignment are fully and accurately described above by the proper shipping ti me,aM'areclAIasus�ified,packaged, <br /> ra <br /> marked and Ia readlplankd,and are in all respects in proper mnddlon for transport according to apphcable international and national governmental regulations.if sh�ment�n�a�.Bte,g,ma}�c <br /> Ezponer,I cerrAy that the contents of this consignment conform to the terms of the attached EPAAcIl oxAedgment of Consent. <br /> I ci that the waste minimization statement Iden' 40 CFR 26227(a)(d I am a large quantity generator)or(b)(if I am a small quantity generator)is true. r® /typ�Y62Q <br /> Generalo(s/Ciffe pea Name Ig re ay ear. <br /> 16 International Shipments - <br /> F ❑Import to U.S. ❑Export from U.S. - part of entry/act <br /> Transporter signature far" o [late leaving U.S.: <br /> w 17.TransporterAdmov4edgmem of Receipt of Materials <br /> Transporter lPin ce ,l g o Oy . ear <br /> O v C/ <br /> h <br /> z Transporter 2 Pinped 9 / ,Day ear. <br /> nth <br /> 1 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity, ❑Type ❑Residue - ❑Partial Rejection ❑Full Rein dm <br /> Man deal Reference Number. <br /> 18s.Alternate Facility(or Generator) U.S.EPA ID Number - <br /> J <br /> U <br /> a <br /> LL <br /> FaditysPhone: <br /> 18c.Signature ofAltemate FaMtyI-Generator) - Momh ,Day Year <br /> Q <br /> 2 <br /> CD 19.Hazardous Waste Report Management Method Codes 0.e.,codes for hxmrda,s vrdste treatment disposal,and recycling systems) <br /> p 1. 2. H040 3. 11040 4' <br /> 20.Designated Facility Owner a Operator CertCvation of receipt of ham5W materia/lssAwyemd by the martAedeuspt led" t 1118 <br /> Prkaled7fype0 Name _ .T �� CV1� <br /> 77 11 A Iy <br /> EPA FtumCL:2c'�Po�1b:C".7s1 C1� cyJ. y;. J,-r. E:;d 1nD acGGys 6I^�am40 8Ca c^MMTU,T, IWury TO GENERATOR STATE(IF REQUIRED) <br /> v 12164.0693 <br />