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RECEIVE <br /> P ease pdnt or type ForrinmInved.OMB No,205MO <br /> UNIFORM HAZARDOUS 1 Generator ID flumb� G <br /> p . ryryPhone A u.M1445636iX <br /> Number <br /> WASTE MANIFEST CQ89Q09=2 �.� ma�ng <br /> 5 Griletabes <br /> ralOr's and MEd tab Site 3OD an b lhW of U5 N MA Wwi L�it/!lllaOrtd�Ne!of�Um 3As 3OD o.blW&US WM <br /> PA.Boa[SM/ON WetI1Nlpfe CA 9651 GGrrd Hdbw Rood,T1aGSf CA 9537Ii <br /> Gerremrads Phone:9254M-I9a Anft Sit PPV <br /> E Transporter t Carr,"Name U.S.EPAID Number <br /> Clean Harbtxs ErMronmentai Swvkes Im 9322250 <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Oesignated FaaTdy Name and Site Address U.S.EPA ID Number <br /> Dean Harbors VW"Vrrgtt9fl►LLC 17D E.WM ere llMibllitpton CA W7" CAD0444MS <br /> Fadll�*Phone. 31.)iM-M99si <br /> ga, W U.S DOT Dasmptim(urdrrdntg Pmper Shpping Name,Hasid Clan.ID Number, 10.Conbthtera 11 Trial 12-Un4 13.Wade Catles <br /> HM and Packing Group(tl any)) No: Type Q WLNd. <br /> 1 *Wl itA islaxardoas WW4 B*gd(WED Oily DdPWWI 4 DM i3si3 P <br /> te <br /> 222 <br /> w 2 NOWRCi A hnardaM Wate,NqUid(USED ay DOPWID-1 2 DM M P <br /> 221 <br /> 3.Non-ciao►t HgWd(USED OIL)DOP0080-1 4 DF an p <br /> 222 <br /> 4. Non-MAh=fdo=wiftiig"(USEDauDOPMI)aj 2 DF 34 P <br /> 2u <br /> 1 Special Hands stnxsicns and <br /> 9== DA=4L 2 .sxos cD�r t�i, u.NL DkPotdL i.Wd 9 wuza�.�ia�D«n� <br /> S-� �r,��Rear mondial 1.XE,Q�on k wdM Sae attadted for CoratdnW numbers. <br /> 7�!� <br /> GENERMT)R'SfOFMRtOR'S CERTIFICATION I here Brat the cordenb d Ibb aautg MWd are Tiny and accurately desalt' ebM by She proper ehadno ramie,and are dassited parkaped, <br /> marked and lebefedlptacarded.and are In as mgm:b In proper mnditlan for Uartspod 9=rdbg to appkabb IntemaWndand na0onal govemmerU mgubtians.I effort shipment and I wit the Primary <br /> Ixponer.I certify thal ft conwts of the consignmmit caftan to the lama of the abadred PAAdwv*adgmem mt Consent. <br /> I oertry that the wade minimhalton etatemerrt WOW In 40 CFR 20217(s)(d I am a large qua*generator)or(b)(11 am a wN quantity r Is he. <br /> Genrerato eOfteroes PrinteCyped Nairn Sgnatwo AApn1h Day Year <br /> SCOtt A.Gra#tiam on behalf of US NWA <br /> a 18.Intema0mal Sh ip is <br /> ❑Impart 10 U.S. ❑Export tom U.S. Part of entrylei <br /> E= Tc mpovter si r"m(for expcns of Date leaving U.S.; <br /> 0= 17.Trargponer of Racelpt of IAatarlab <br /> Trargxrtar 5g Mordh Day Year <br /> J `44 2 <br /> Transporiv-2-Prii6rhyp6d Name Sp ahrm Month Dal Year <br /> 10,Diwepency <br /> 1Ba Ugaepancy Inrtication Space ❑ Duanbty ❑Type ❑Residue 7"Partial ReJ d' ❑FW Rejection <br /> rii Rafami <br /> 18b.A.Iernate Fac0ity(or Generator) U.S.EPA ID Number <br /> _i <br /> ra <br /> u Fadpty's Phone: <br /> 1 Be.Signature of ARemato FaaGly{or Genaratu) Mora Yam <br /> ui 19.fimmlous Waste Report Management MejW Codes(f.e.,codes for ham*w wasla beatrnent,06patial,and mcy*g systew) <br /> Gi <br /> 20.Designated Fai a CertiBcaban of tecapt of h�n3m mxe r�wred by the manlest except is tlem <br /> PnnbxgTyped Name ,V v Y1 qn I}al ar <br /> e , orm 8700.22(Rev.12-17) Previo eftfiesm oll DESIG P TO EP s e-MANIFEST SYSTEM <br />