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M <br />P4lturr urvd or tmxa- <br />II I II I I I I! 11 I I ILII II til II till III I III <br />0 0 6 6 5 7 1 2 3 S I:. S <br />Form ApInoved. OMB No. 2050-0039 <br />EPN%-RHI V1. <br />bwriouseditionsareobsolete. DESIGNAT ED FACILITY TO EPA's e -MANIFEST SYSTEM <br />UNIFORM HAZARDOUS <br />C=enwatof ID NUr"OU <br />(;E:�, q1 (A 1; <br />2, Page l of <br />I <br />3 Emef enc Res se. Phune <br />'��'' 'f� 1 tf't <br />4, Manifest Tracking Number <br />006687123WASTE <br />SKS <br />MANIFEST <br />1111n8 and Mailing Address Geneiralor's Site Address (if different than mailing address) <br />iibo, C -a) i f-L-,rni&.- Ci i:f-{ j}!'' t'!:: ".i;. <br />PIANTIFCA <br />-me(ator's P,h]one C,IJIr� ' ,r-9 �i(i ''? ;'':)i <br />6. T�i I Y`'f tL� •- YE— i E' PI`. I f U S EPA ID Minter <br />� <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />CLEAN HARBORS ENVIRONMENTAL. SVI 'INC. f,,I<f,, ; ; •,:: ,,,k> <br />8 Designated Facility Name and Site Address CLEAN I'!i RBOR , F.NV1TM ('li - NTf'4L. F;r R+VL 'f Ci, 3-m— U.S. EPA ID Number <br />- - ' - ; FlY '71 G41*A 30 u <br />I`.;�- +f" 1�II <br />-l. I?JGVrI '�`+� .-`7.::� <br />Fr'alily's <br />Phone: <br />9a. <br />91h. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13 Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.No1 <br />k <br />t UN1268, I�JAGTE. ^1. iI-R-F )M DT ITTI.13-i I `t -, <br />i;h! <br />}:i><l�. <br />L.11,1,o <br />T <br />N.0,--, PIS TO <br />w <br />z <br />LU <br />l.7 <br />d <br />14 Special Handling Instructions and Additional Information TF'1):4+ ?' ,;190 <br />1 ) I-Rf3,tj i- 8' <br />4H ! IY1Ff�G NCY#8�1?�-4fr:�-f 7E C:E{iSKiTFI �:onLr cr retained r,y -1,0(ETtry author; <br />t• <br />an initial transporter to add or 5t-Tb5titrtte additional transporters on a E._ r's behalf. <br />15. GENERATOR'SIOFFEROR'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 EPA Acknowledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(x) (if I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />Signature Month Da Year <br />Gerrralorsy0fferot's FhintedAypedName ignaturo Y <br />14Oki 1=7 ute-, ta(I _ )I �o I� <br />16 International Shipments <br />11Import 10 U.S Export from U.S. Port of anlrylexil: <br />? <br />Transporter signature (for exports only): Date leaving U S,: <br />W <br />LLJ <br />17, Transporter Acknowledgment of Receipt of Materials <br />Tra er 1 Pri ed/ryped ZC Signa Month Year <br />coCL <br />Transporter 2 Printed/Typed Name ignalure Month Day Year <br />Q <br />rY <br />18, Discrepancy <br />�- <br />18a, Discrepancy Indication Space Quantity I __I Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br />Manifest Reference Number: <br />18b Alternate Facility (orCeneralar) U.S EPA 10 Number <br />J <br />U <br />LL <br />Facility's Phone: <br />LU <br />18c, Signature of Alternate Faci ity or nerator) <br />Month Day Year <br />a <br />z <br />19 Hazardous Waste Report Management Method Codes (Le., codes for hazardous waste treatment, disposal. and recycling systems) <br />o <br />t <br />2. <br />T7 <br />4 <br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18a <br />PrintedfTyped Name Signature month 0ay Year <br />EPN%-RHI V1. <br />bwriouseditionsareobsolete. DESIGNAT ED FACILITY TO EPA's e -MANIFEST SYSTEM <br />