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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) 717964$9$ SC PPW 8/6/2013 Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone4 9 6 4.Ma�fe�Trg Id Nump r <br /> WASTE MANIFEST 2- 0 0 66 6 55 55 FLE <br /> 5.Generator's Name and Mailing Address Generators ite Address(it different than mailing address) <br /> MCI <br /> PO Box 725 13850 North Devilries Road <br /> Chino.CA 91708 Lodi,CA 95242 <br /> Generator's Phone: <br /> ansporter 1 mpany ame U.S.EPA ID Number <br /> Clean Harbors Environmental Services Inc MAD 0 3 9 3 2 2 2 5 0 <br /> 7.Transport 2 Company Name U.S.EPA ID Number <br /> 6vQD y tJ� <br /> 8.Design ed Facilit5rName and Site Address U.S.EPA ID Number <br /> Clean Harbors San Jose LL <br /> 1021 Berryessa Road CAD 0 5 9 4 9 4 3 10 <br /> proose.CA 95133 <br /> Faci i s hone: <br /> ga. 9b.U.S.DOT Description(including Pro Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity WIJVoI. <br /> 0 1 NON RCRA HAZARDOU WASTE LIQUIDS.FOIL DIESEL) D / p`N3 <br /> 2 j 'l,' w <br /> UJI <br /> 3. <br /> el <br /> 4. <br /> 14.Special Handling Instructions and Addl tionaJ Info,rnaton <br /> 1-CH587345SX <br /> M(p 7T-7q <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 EPAAc knowfedgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator) <br /> — or ) eat )is truer <br /> neraero ssPamp)Jie gra re <br /> Month ay e <br /> ar <br /> g 126113 <br /> 1 16.International Shipments a <br /> Z 11Import to U.S. ElExpertfrom U.S. Port of entry/exit: <br /> Transporter signature for exports only): Date leaving U.S.: <br /> w17.Transporter Acknowledgment of Receipt of Materials <br /> Transpo er 1 Printed,[Typed Name gnatureMonth Day Year <br /> CL <br /> K , Y 4- q104-113 <br /> Cf) <br /> Transporter 2 PrintedlTyPed Name I 5gnature Month Day Year <br /> KC <br /> 1ke <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El <br /> Quan' El Type El 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 /> Q <br /> LL Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) <br /> Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> H141 2' 3 a. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Name S Doth Da Year <br /> Myped <br /> -05) Previous edition are b solete ESIGNATED FACILITY TO TINATION STATE(IF REQUI D) <br /> Clean Ha ors has the appropriate permits for and will accept the waste the,generator is shipping. <br />