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0 <br /> Please pent or type.(Fam desigred for use al elite(12p ich)tyleWtarfJ 1702984126-002 SC PPW 5/30/201 i' Form Approved.OMB No.7.050-0039 <br /> JUNIFORM HAZARDOUS 1,Gener"IDNimeor zMaIM 3.EmergencResponse Plane d.lAanaed TocId Numher <br /> STE <br /> WAMANIFEST CAD983600594 2 800 4833719 01037223 FLE <br /> 5.Genemlas Name and MaiFingAddrew Gtnaetas Sita Adder,(a deemnt aun coming addren) <br /> Kaiser Permanente <br /> 7373 West Lane 7373 West Lane 0109446 <br /> StodRon.CAS5269 I Stadtmn,CA95210 <br /> ck n sphow R ATTL•Iueero Cav n- <br /> na, Nam uo� U.6, IRAMNumaor <br /> Clean Harbors Erwironrnental Services.Inc, MAD 0 8 9 2 2 2 5 0 <br /> 7.Tmreporler2 Company Name <br /> US.EPA 0 Rater <br /> 8,Desognead Fwaty Nara antl SireMtlreu LLs.EPAIDNumber <br /> Clean Harbors ArUciftite ILC U T D 9 815 5 217 7 <br /> 11600 NorthAptus Road <br /> A e.UT 94029 <br /> 9,, 9b.U.S.DDT De5wp5on(r jj Froper5hgpk Name,Kuord Chis,ID www. 10,C0"L* S 11.Ta1a1 12.Ud1 13.Waste Code, <br /> NM and Packbg G"Vany)) No. TYpa Qan6N WLIM. <br /> 1. <br /> o UN1993,WASTE FLAMMABLE LIQUIDS,N.OS.. 0 01 D F 0 0 0 6 3 P <br /> X OSOPROPAHOL),3,PG 11 <br /> W <br /> w 2 UNi493,WASTE SILVER NITRATE,5.1,PG II 0001 D01]. 551 <br /> 001 DF O-DO04 P <br /> X <br /> 3 UN3249,WASTE MMaNE.SOLID,TOXIC.N_OS- 0 0 i DF 00004 P P <br /> X fWARFARIN16.i.PGill <br /> < UN28iO.WASIETOIUCLN2111DS,ORGANIC,N.OS, 0010 UO3!i U058 <br /> X (hELPI AAN,CHLORAN�IICILL 6.1,PS 11 —T--K 0 8 012 9 P <br /> U069 U160 661 <br /> 14.$pedal Melling InTuAaS awAddtk ml Inbnralion rtEETIr5s47-let vA of P-LMedwam an Lim <br /> 1.LCCRO ER.G$128 1x55 nem:3 is 4vams <br /> 2.L4CRO ER6$140 1X5 <br /> 9_CH1212415 1:R6�151 1X5 <br /> 15. GENFFATORByOFFERORS CERTF7CATION: I ceche A;0. 1As daiim5lgrirtadam ftayendam,etdy described above bylne proper sidppirg nam.and as tlanfied.prkagad, <br /> marked and wiwedipMutd d.and am In al respect N Propel cenenca br 0anseel accaGna to eppYwde Iniamefenat and national i"wemU regNarbrs.9 expos sMpmbd ad I con the Nin" <br /> Expod ,ladHygaltheerrden5dei,MnSomeMcunhrmbin,YsmsatOwatbdwEPAAdraWedgrmnlOfCPnawu. <br /> I ceiby Nat Ne waste mirrmuation WAamenl Winged in 4)CFR 36217(a)(d l an,a large quanbly (b)(Alam bWA WnnSHganeaw)is tn+a. <br /> teneratoSI aY ear <br /> t <br /> J0;1nk na 134:m nu <br /> EzpoRlmm US.—>�minrerltrYlm>t:_�- — <br /> 1-4 <br /> T er mane fa Dalelenng US! <br /> rY 17. ean,PowArArudedgmmlol Recdpld Maledak <br /> ay ear <br /> 0 mnspalet 1 Pilled yred Nane d <br /> a <br /> 3N3 ane0an� ) � Signakwe ea. <br /> a 1A0.s2 t/La T t' 1I�� I') ti c �l� <br /> t- 1e.Disaeparxy <br /> 1aa.0isuepang1ndo6on Space ❑ Ouenbt/ EITYP. ❑Residue ❑paliN Rejectiai ❑Ful Rryedbn <br /> Ma9led Rda aga Number. <br /> tab.Plumate FvAty(a Garembr) —__ V9-EPMON'anbar. _— <br /> ? <br /> LL< <br /> Foul s Phut: <br /> wIac.SqurueufAbwm FadMy(a Gerdrdta) Menta Day Yea <br /> 4 <br /> Z <br /> N19.Hazardous Wazte Aepal Mau9emerA Meaad Codas ea.,codes fw�avNan wast bearrnenl.tl6poael,and reydrg ryelema! <br /> o t z 4, <br /> W 3. <br /> HMO H040 H040 H040 <br /> 1 2d.Dei giwbd Fedgly Owmr or Operator.CeAflceaon d receipt of hazadbu6 mater®ls covered M Na mauled emeplas soled n aem 1 k <br /> PdnreNfyped Name < � Siyaoae � AMtlh D-a�jV Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions em dbotele. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> clean Harhars has the ippropdate permits for and will ateept the waste the generator is shippiW, <br />