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:L o11K stiIr,# t,71iw'"IE:.s II�'III�II7 5II�IIII�II��I��II <br /> Form Approved,OMB No.2050-0039 <br /> Please print or type. <br /> I.Generator 10 Number T_: 2.Paged of 3. m c J Re}po9se Pltyi�� 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS CAL.4'�00���'"���� L ��-��'� 0 0 6 6 8 7 5 9 5 SKS <br /> WASTE MANIFEST <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Bardrtc,;• Tr—i f:I.T!ul <br /> MANTFCA <br /> � 04'"'2'49–,_204 <br /> Generators Phone. U.S.EPA ID Number <br /> s.TptsaTv SYSTEMS INC <br /> U.S.EPA ID Number <br /> 7.Transporter 2 Company Name MPT10 71`37,:;22 .50 <br /> CLEAN HARBORS ENVIRONMENTAL_ Si INC. <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address CLIFTIN HARPOP S CAN TOSS <br /> 't021 BFRRYESSA RHAB <br /> SRU JO-E CA 9SI?: 7r µga ,0 <br /> r,Aj(, y :. <br /> Facility's Phone: <br /> 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, JNo. <br /> *TypeQuantity <br /> 12.Unit13.Waste Codes <br /> 9sWLNoI.HM and Packing Group(rf any))<:LT'� F :+PttGLf WRSTFSCILiu <br /> o (CIIL, FtI-'.EF.3) <br /> a <br /> Z 2. <br /> w <br /> 0 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information T :1t 2. 7 x -7. 1.='7` 9t;• — - y <br /> 2-4Nt fn, 0 Inx bS taaa r s a i s>it F:nt t <br /> Off initial trans Drter to add or s_t=.t itite eddittan t <br /> 15. GENERATOWSIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are dassified,packaged, 4 <br /> marked and labeledlplacarded,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 catty that the contents of this consignment conform to the terms of the allached EPA Acknowledgment of Consent. <br /> I pertly that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is hue. MonthDay Ye <br /> Generators/Offerors Pnnfed(Fyped Name <br /> Signature C/J! <br /> 16.In atonal Shipments ❑import Ic U.S. ❑Export fro S. Port of entrylexiC <br /> Dale leaving U.S.: <br /> ? Transporter signature(for exports only): <br /> + <br /> W 17,Transporter Acknowledgment of Receipt of Materials Month Day Year <br /> 7 oner1 PnntedlFy e Signa <br /> v.�et�c? 6 <br /> a Signature Month Day Year <br /> Z Transporter 2 Printed/Ty ame <br /> In <br /> r <br /> e s <br /> 18.Discrepancy <br /> 183.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection Full Rejection <br /> Manifest Reference Number: t <br /> U.S.EPA ID Number <br /> 181a.Alternate Facility(or Generator) ' <br /> J <br /> U <br /> LL Facility's Phone: Month Day Year • <br /> w 18c.Signature of Alit mate Faddity(or Generator) <br /> a <br /> z <br /> y19.HazardousWast ReportMaria ement Method Codes(i.e.,codes for hazardous waste treatment dlsp3sal,and recyding systems 4 <br /> w 1 2, <br /> 0 <br /> 20.Designated Fail r or Operator. rtficabon of 1pt of hazardous materials covered by the maiganifest oat excapt as 0 in 18a n a <br /> Il re <br /> PnntedlTyped Name \ <br /> EST SYSTEM <br /> EPA F m87Q0-2 tRe; <br /> vious solaria. DESIGNATED FACILITY TO EPA's e-MANIF <br />