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Pleaseon[or". Form designed for use on eltfe 2-pitch wriler. 104630373-002 SC PPW 3/3/2ali Form ed.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1. Wrator I P4e 1 of 3 Response Phone <br /> WASTE MANIFEST CAL 0 0 0 3 4 7 3 3 8 1 (800)4933718 0 5 5 5 7 4 8 F L E <br /> PaACI nen+ ams a ng e <br /> w Address(If~than malling address) <br /> PO Bat 725 13850 North Bowles Road <br /> Chino,CA 91709 Lodi,CA 95242 <br /> Genarerora ne:(908162 ATTNZaoh Faindold <br /> mpany EM rU Number <br /> 4 <br /> Clean Harbors Enviroemdntal Services Inc MAD 0 3 9 3 2 2 2 5 0 <br /> U EPA s) <br /> Winter <br /> 'O '�l � <br /> DeqnaW Fadly Nws and .S.EPA ID Number <br /> Clean Hwbors San Jose L.0 CAD 0 5 9 4 9 4 3 1 0 <br /> 1021 Ben ossa Road <br /> San Jose.CA 95133 <br /> Fadto Phare <br /> sm. 9b.US,DDT Desalptlon ondudlnp WW SMppkg Name,Hazard Class,ID Number, 10.Containers 11.Total 12 Unit 13.Wads Codes <br /> HM and Paddttg Group IN any)) No. Type Quantity WLNoI. <br /> cc 1 L1 <br /> O <br /> F— <br /> '-NON RCRA HAZARDOUS WASTE SOLIDS,(OIL,DIESEL) A2 <br /> �Q <br /> M 75 P <br /> 3. <br /> 4. <br /> 14.Special Handing Irwhictions n <br /> . HS87246 <br /> 15, GENERATORISMFFEROR'8 CERTIFICATION; I hereby doctors that the contents of this consignment are fully end aawaWy described above by the Proper shfpplrg name,and ere daesilled,packaged, <br /> marked and labeledrplacarded,arx1 aro to a0 maps=in propercand ow for transport according to appscebis International and natiormi governments!rogutatiau.It export shpment and I am the Primary <br /> Exporter,I cerBfy that the contents of this consignment conform b the term of the stadted EPAAdmowtedgmmnt of Consent <br /> I certify Oat the waste mtnmUdon stalemant Idantif ed In 40 CFR 26W(a)(111 am a large quadv generator)o(b )Is tore <br /> M" Day <br /> znt <br /> me <br /> ma <br /> to U.B. Export from U.S Pat of onv#eAt: <br /> T SV-M--( fat i i on Date teryiN U.S.: <br /> 17,Transporter Admowledpmenl of Receipt Of Meredala y <br /> Transportere <br /> a <br /> m <br /> IL <br /> 18.Dfsorepency <br /> 1Ba.Disaepwq btdiradon Space QuanRy ❑Type ❑Reetdue ❑Partial Ralection ❑Full Raiedion <br /> Manifest Roferena NumW <br /> 18b.Altemere FecOtty(or Gsneraror) U.S.EPA ID Number <br /> W Fact6Phone: <br /> G 8 re mate or enarator) VonM Year <br /> 52 19.Hazardous Waste Report Management Method Codes Q.e.,codes for hazardous waste teatnwt,&spoael,and regc[In9 syslamm) <br /> 1• Hi41 2. 11i41 3. <br /> 4. <br /> 20.Designated Fadity Owner of Operator.Certfficadcn of recelpt of hazardous matadale covered 4 Om mw"except u noted In Item 18a <br /> n ere , <br /> sivetune Wngr <br /> EPA Form 870022(Rev.3-05) Previous edttlons are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />