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Please Ppnt or type.rForm designed for use al elite(12-pitch)typewdlecfJ 1702984126402 SC PPW 5/30(20il Form.Vploved.OMB No.2050-0039 •-UNIFORM HAZARDOUS 1.Genal""Number 2.Page f of 3.Emergency Response Phone 4.I3anHest Tracking Number WASTEMANIFEST CADS836.00594 2 800 463.3719 010887223 .FLE 5.Generetor's Name and marring Address Gerteratofs Sore Andress(8 differed Than mai6rg atldreu) Kaiser Permanente 7373 West Lane 7373 West Lane 01094418 Stockton-CA 95269 I Stod tnn,CA 95210. Geneatoes Phone:. E_—ATrla-lessiea Cavan 1� 6.Tansponer ompany Name U£.EPA IO NurAar Clean Harbors$nvironmental Services,Inc. L,M A D 0 3 9 3 2 2 2 5 0 7.Transponder Company Name _�^ .EPA ID Number -- d Onignated Fadlity`N'ama MSee Address 11IIllllllkO�ll2luult III�J' 2017 U8.EPA ID Number Clean Harbors Arakonite LLC `SEP ' 9 UTO 9 815 5 217 7 1:1600 North N.��orthAptus Road ENVIRONMENTAL HEALTH Farntysllle.UT 64429 Ty4� pcRMITISERVICES ga, 9b.U.S.DOT Description(inducing F miner Shipping Name,Heard Class,ID Number, id Containers 11.Total 12.Unit 13.Waste Codes XM and Packing GmuP(if any)) No. Type Quantity WbNm. 1. rz UNi993,WASTE FLAMMABLE LIQUIDS,N.OS.. t55j-- 0 x pSOPROPANOL).3,FG 11 0 01 DIF 00063 P z, 0001 DOid. 551 UN1493,WASTE SILVER NITRATE.5-1.PG 11 001 OF 00004 P X 3. UN3249,WASTE MEDICINE.SOLID,TOXIC,N.O.S., 001 OF 00004 P P001 1 x (WARFARINI.6.1.Ki It UN2810,WASTE TO:KICLIQUIDS,ORGANIC.N.O.S, UOiQ UO3!i 0058 x t[MELPHALAN,CHLORAMBUCILS,6_1,PG It 0 08 D F 0 012 9 P UQ69 Ui6l) 561 14.Special Handling I90FOrrs a dAdcrtknal Information FLEET108547JIH WI:of P-Listed Wattle on Li 1.LCCRO ERG$125 1X55 Item,S is¢grams 2.LCCRO ER.G9140 1X5 3.CH1212415 ERG$.151 1x5 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of Ws oansignmend are fully and accurately described above by the proper shipping nacre,end are dauRed,VxXaged, marked and Iabeledrplacerded,and an!In all respects in proper condition For unspent according to applicable international and national llovemmentul regulations.N expot shipment and I am the Primary Exporter,I teddy that the contents of this cmale ent oankam to the harms of the attached EPAAcinowledgment of Consent. I minty that the waste midmization attendant Mentlfled in 40 CFR 26227(x)(4 Iam a large quantity ge r) (b)(6I am a small quantity genealor)Is tme. eneralor mrs nie yped me A ,� �T1oi�lay ear F 16:Inlamational Shipments ._ - — ""-""' IJ --^ -• lmporlm m U--- I LLS. UExportlm S. z T er signature ifor exports on Date leavirg US_ K 17.11tansporterAclknmNedgment of Receipt of Materials Trepoder l Primed yped Name Signature onN ay eat ns O tL Z Tmnsponer Ph IT yped Name ^Ce ay e� K¢ C(Ved 18,Discrepancy 18a.Discrepancy Indication Spare El Cranky El❑TypesResidue ❑Partial Rejedbn ❑Ful Rejeclion __-..- _ MarNest Reference Nu+Ibx: 18b.Alternate FaraBy(or Generator) – VSfPA1BNtanber-- ---- U LL Facill 'S Phone: w 18a SignaNreolAllemate Fadlity(or GerreratorJ Month I Day Year 2 - a—i 19.Hazardous Waste Report Management Method Cedes(i.e,codes For hazardous waste treatment,disposal,and recydirg systems) _ � 1 2. 3. a H040 40 H040 H040__ 20.Designated Facility Owner or Operator.Celtlfration of receipt of hazardous materials covered by the manifest except as noted in here 13a Ponted/ryped Name < 8ignaMe Month Day Year ( �✓� -- ---1 4 (7 EPA Form 8700-22(Rev.3-05) Previous editions are dbsotp.te. DESIGhATEO FACILITY TO DESTINATION STATE(IF REQUIRED) Clean Harbors has the appropriate permits for and will aoeept the'Waste the generator is shippieg..