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RECEIVE <br /> P ease pdnt or type ForrinmInved.OMB No,205MO <br /> UNIFORM HAZARDOUS 1 C�enerewr ID Nurrtav G <br /> p . gyPhone A u.MJ445636JJK <br /> Number <br /> WASTE MANIFEST CQ89Q09=2 �.� ma�ng <br /> 5 Gaiwabes <br /> Us and MEd tab Site=an bt:!hW of U5 N MA Wwmwe L�it!!lllaorttt�Ne!of�Um 3As 30D o.blW&US WM <br /> PA.Boa[SM/ON WeI17110 a CA 9651 GGrrd Hdbw Rood,TtSGy CA 95376 <br /> Generatda Phone:9254M-I9a Anft Sill PPV <br /> ti Transporter 1 Corrgany Name U.S.EPAiD Number <br /> Clean Harbors ErMronmontai Swvkes Im 9322250 <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> 8.fksignated FaaTAy Name and Site Address U.S.EPA ID Number <br /> Dean Harbors VW"V tgtM U LC 17D E.WM ere VMibllirpton CA W7,14 CAD0444MS <br /> Fadm ev Phone: =405�M998 <br /> ga, W U.S.DOT Desrnpbm(urduding Pmper Sib iag Name,Hazard Clan.I D Number, 10.Combines 11 Trial 12-Un4 13.;Haste Cedes <br /> HM and Pad3ng Group(H any)) No: Hype DiINLNd. <br /> 1 N fl itA islaxardous WW4 Wid(WED Oily DOPWWl 4 DM I= P <br /> 222 <br /> w 2 Non-RCRA hnardaM Wale,�d(USED ay DMIND-s x DM M P <br /> 3.Non-ciao►MWri"waft*W(USED aU Douai 4 aF an p <br /> 222 <br /> 4. Non-fiCliAh=fdo=wiftiig"(USED auDop=j)4j 2 DF 34 P <br /> 221 <br /> I Special Hands s9ln =and <br /> 9== DA=�'° 2 a os cD�r t� u�w. ar.iWa r wuza .�ia�D«n� <br /> S-. r,��Rear nuns W 1.XE,Q�on inwoim Sae atta%W for CoritdnW numbers. <br /> LiENERATOR'Sf 3FFEROR'S CERTIFICATION I here tlrat the mrderrb d Ihb conaignrr eM are Tiny and accurately dr»albed above by"WoW shlppinp rww and era dassiW parkaped, <br /> marked and lebefedlpiacarded.and are in as mgm:b In proper mrditfan for trenspod 9=rdbg b app mbb inlemati inland naOonal govettrtWU regulations.N export shipment and I em the Primary <br /> Ixponer.I teddy that the omwts d the wmsgn omt conform to the lama of the aWad PAAdwmAW9mem d Consent. <br /> I oertry brat the waste minfmhalion etatemeM Idenetied In 40 CFR 2021T(a)(If I am a large quantity peneralor)or(b)(NI arrr a smrBT rprantny r b hue. <br /> GenerviWeOffemes PrinteCyped Nam Sgnatum Month Day Year <br /> Swat A.GraMm on behalf of u5 mwA Ee z tw. <br /> a 18.Intemahmal Sh ip is <br /> ❑Impart 10 U.S. ❑Export ham U.S. Part d entryler, <br /> E= Trargporter signawre(for exurb Dory): Date leaving U.S.; <br /> tY_ 17.Trargponer d Racelpt d Matariab <br /> Transxrter 5g Mmtlr Day Year <br /> J `44 2 <br /> Transporiv-2-Prii6rhypid Name Sig ahrm Month Dal Year <br /> 10,Diwepency <br /> 1Ba Dgaepancp krrtication Space ❑ Duo" ❑Type ❑Residue 7"Partial R*d, ❑FW Rejection <br /> rii Reference <br /> 18b.A.hernate Facilk(or Generatcr) U.S.EPA ID Number <br /> _i <br /> u Fadray's Phone: <br /> I k Signature of ftcr FaaGty{or Generator) Mora OMYem <br /> ui 19.fiaurr&ws Wash Report Management IAetflod Codes(f.s.,codes for ham*w waste heahneri 06patial,and racyciFtg sysiew) <br /> Gi <br /> 20.Df97 <br /> Fac7ty a Certificahanolr�ecaptofh,a�cwsmde r�wreebythe+nanifeste�ept inllam <br /> Pnntarne ,Ve , ormtw 2z(Rev.12-17) Prefod edh6esmolrsale DESIG F To EP s a-MANIFEST SYSTEM <br />