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331_ '35 SHIP# 225562&15 <br />Please print or Wm (Form desloned forum on elite (12 -Ditch) tvDaWler.) <br />Fnnn Annmved. OMR Mn 9ngMAiQ <br />EPA Fon 5700.22 (Rev. 3-05) Previous editors are obsolete. <br />GENERATOR'S IMIT1AL COPY <br />UN;1F <br />1. Generate lD Number <br />?Page l of <br />3. Ennmgetxry Response Phone <br />4, Manifest Tracking Number <br />ASTE MANIFEST <br />CAL9.0004300 <br />1 <br />1-Ei FC- c}68-1 "U, <br />p p r 20910 SKS <br />5. Generator's Name end Matling Address Geraretors Site Address of different than mating address) <br />Kia C -fit ry <br />1:515 N Main S# <br />AA04TEL'A CA ?5?:3a-i2tia' <br />Generators Phone: 999 <br />B. Trenspoder l Comperry Hem US. EPAID Number <br />S3 FETY-KLEU; SYST6:4!S INC. 12.q <br />7, Tmneporar 2CompM Name LLS. EPA ID Number <br />CLEAN HARBORS ENVIRONMENTAL SrdC 1W. <br />S. Designated Facey Name and S teAddreea CLEAN JOSE U.S. FPAID Number <br />IiARP•G::S SAN <br />1021 BER9 ESSA RI IaL <br />SAW I DSE wi ?5.:33 <br />Facility's Phone: <br />9, <br />gb. U.S. DOT Des riptlon (including PmperShlpping Name, Hand Class, ID Number, <br />1D. Contaners <br />11. Total <br />12. Unit <br />HM <br />and Packing Group (geay)) <br />Quantity <br />W1Nal. <br />13. Waste Codas <br />No. <br />Type <br />1. <br />?4P.307-1 h'f-17'aiCia;'I„f-'• v:j1:.i7•Ci MUD, V, ti, �i. <br />.Sk>� <br />C' <br />L1•4jhjj_ II'S.r,. <br />y { I <br />C 2]i <br />C_L. .. <br />w <br />' •r . <br />W. <br />...,_._ <br />....-•eV+r'M�•�fF• �;iCtS�^%%�T}T.T'il�i�,SL"'+�vy.-'i u."�'�"daL�"Je .. _. __-._ <br />r))-'T::tfit��v4i=-t:A'•iat--il.J.t,ly.-��(,""i� <br />_...... .. <br />:rift.. <br />_ .11.. <br />. ..;� <br />- <br />3. <br />4. <br />TT�) <br />i <br />14. Special Handling Instructions and Additional Information <br />Tar” <br />#1-800--66-1750 f f -t~ SV. ., 7-1' <br />15. `GENERATOR'SIOFFEROR'S CERTIFICATION: Ihereby decele 60flui cdnlents o715is'cddmgm`nent are Htly'andacasatefydasel�edafiove li IDe pmpei shipping name, and am classified, packaged, <br />marked and labeled/placarded, and are bi as respects In proper condlfion for transport acceding to appticzble inlerrabond and national govemarenml regulations. If export shipment and I am the Primary <br />Exporter, I oedBy that Ne contents of this consignment mftm to the Win of Ne attached EPAAckn ry ledgrrent of Consent. <br />I certify that the waste minimization statement identified In 40 CFR 26227(a) (dI am a large quantity generator) or (b) (DI am a smell quantity generator) Is true. <br />GenwaloesWemrs PrintedrTyped Name Signature Month Day Year <br />, <br />F <br />16. Intemadcral Shipments —' <br />E] Import to U.S. El Export I. U.S. - Podoferay/exR <br />Transporter signature (for exports only): Date leavig U.S.: <br />old <br />17. TansporarAclmoHkdgment of Receipt of Materials <br />KTrenaporter <br />l PdnWyped Name SiignalurI Month Day Year <br />y- <br />t <br />QTrenspader2 <br />—PW tedll'yped Ne me Slgnaare Momn Day Year <br />4. <br />18. Discrepancy . <br />185. Discapancy Indication Space F1 Duanti ty El Type ❑Residue ❑PanlW Rejection ❑FWI Rejection <br />Manifest Reference Number. <br />18b. Atemate Facility (or Generator) U.S. EPA ID Numaer <br />J <br />U <br />LL <br />Fadlltys Phone: <br />18c Signature of Altamaha Facility(a Generator) <br />Month Day Year <br />d <br />Z <br />19. Hazardous Waste Raport Management Method Codes De., codes for hazardouswaste treatment disposal, and recyc ing systems) <br />p <br />1. <br />2. <br />20. Designated Facility Qwkror Operator. Certification of receipt of hazardous materials covered by the manifest except as now In gem 18a <br />11 <br />Pnnledfryped Name Signature moo Cay Year <br />EPA Fon 5700.22 (Rev. 3-05) Previous editors are obsolete. <br />GENERATOR'S IMIT1AL COPY <br />