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Form <br /> Please print or type.(Form designed for use on elite(72-pitch)typewriier?31700541870 SC PPW 1/4/2017 Approved.W13 No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL 0 0 0 4 2 0 3 3 8 Soo 43-371$ 010512477 FLE <br /> 5.GeneraWs Name and Mailing Address Generator's Site Address(rt different than mailing address) <br /> Ultracotr Inc <br /> 2763 Boeing Way SAME <br /> Stockton.CA 95206 <br /> Generator's Phone:(2091983-3744 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Clean Harbors Environmental Service,Inc. MAD 0 3 9 3 2 2 5 0 <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> S ; <br /> 8. esignated Facilily Name and Site Address U.S.EPA iD Number <br /> Clean Harbors Aragonite LLC U T D 9 91 5 5 21 7 <br /> 11600 NorthAptus Road <br /> Grantsville.UT 84429 <br /> Facility's Phone: <br /> ga, 9b.U.S.DOT Description(including Proper Shaping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.V aste Codes <br /> HM and Packing Group(if arty)) No. Type Quantity Wtfvol. <br /> 1.NON-RCRA HAZARDOUS WASTE.LIQUIDS,(DIPROPYLENE � 343 <br /> 0- GLYCOL MONOMETHYL ETHEM <br /> z 2. <br /> LU <br /> ca <br /> 3. <br /> 4, <br /> 14.Special Handling Instructions and Additional Inforimation <br /> 1_CH437587 rx� <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are da ed,packaged, <br /> marked and labeledlplaccarded,and are in all respects in proper condition for transport according to app&cable international and national governmental regulations.lfexport shipment and I a n the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAdrnowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(f I am a small quantity generator)is true. <br /> General roi's Printed[Typed N , na ure , on y ear <br /> D <br /> j 16.International Shipments <br /> Elz Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature for exports only): Date leaving U.S.: <br /> w 17.Tra o rAcknowledgmrnt of Receipt of Materials <br /> X Trans rter Primed(yped Name nature on ay Year <br /> a Frrr r!�' ✓1 r <br /> ZTransporter 2 Printecirryped Name Signature Mont i Day Year <br /> t~ <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space 171 <br /> Quantity ❑Type ❑Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number: <br /> 18b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> d <br /> LL Facility's Phone: <br /> Lo 18c.Signature of Alternate Facility(or Generator) Mon Day Year <br /> a <br /> Z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLJ <br /> D 1. H040 2. 3. 4. <br /> I <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pdrr yped ame Signal a Moni 1 Day Year <br /> FPA Forrr6feai R bCDltasr iauapproona obsolete fits for and will accept the waste t"ne t '��n .ILITY TO DESTINATION STAT (1F REQUIRED) <br />