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SSL <br /> SK SHIpg 22R IIIIIIIIIIIiI IIIIIIIIIIIIIHIilllllll <br /> }-t4�0r't <br /> Y Ple:ise Print or 0 0 5 7 2 9 7 6 7 S K It <br /> type.(Form de- for use on plito(12-pitch)typewdler.l F <br /> UNIFORM HAZARDOUS °rt^APo+o•rad.OM8 Nr.tD57-M)'.b <br /> 1.Ganeml«ID NLinber 2 Pap I of ].Emw enc Res nse Fhme �.Mandeyl TracMlne Namber <br /> WASTE MANIFEST CAL000316396 1—E�0d-48-1760 0057297 <br /> 8 7 SKS <br /> >.GeriemlWs Nxme aN Mm7 gAdMess Genoratols S�:e Address(d dieereit a-ma 9 address) <br /> Diamond Of California <br /> 1050 Diamond South St <br /> STDCKTON CA 95205-7020 <br /> Genamlofs Ph— 209-601-8720 <br /> s.n ,�p=onn�rt�oWVW SYSTEMSINC. USEPA:0N„aee <br /> F1FEf TXR00R0B1205 <br /> 7.rransaoder 2 Company,'L— Us.E"":0 <br /> trx ' <br /> f CLEAN HARBORS ENVIRON SVCS INC <br /> I � MAD039322250 <br /> 8.Uxsgnaled Faairy Name and Sia Add— CLEAN HARBORS ARAGONITE LL-C U.S.EPA ID Nra— <br /> 11600 NORTH APTUS ROAD <br /> ARAGONITE , UT 84029 <br /> UTD9B1552177 <br /> 43:r-884-8100 <br /> Fadi.s Pilare.� <br /> i y, so.U.S.DOT Dewiplen fnclodinr,Proper Shipping Name,Hazard Class,ID Num'xr, 10 Cenla'mars 11,Total 52.Ural <br /> ( HM and Parkig Gra:p(r any)) No. Typo Ganhty NA.P4o I, <br /> 1 nr X ' UN1888, WASTE CHLOROFORM MIXTURE, 6.1, , l UV P D02 211 <br /> r.2 PG III I V <br /> o. <br /> w <br /> + <br /> I rr <br /> I <br /> I <br /> I <br /> l <br /> 14.special Hanchng Insructlpns and Additional Information TSD:AG <br /> DI17225 CSG-. <br /> 1)ERG#I51- <br /> 24 HR EMEHBENCY #1-800-468-1760 (SK / TFI) <br /> SEE ATTACHMENT <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the camper ipong name, are Gasalfletl,packaged, <br /> marked arid labele&plecarded,and are in all respects in proper condition for transport accord°g to applicable international and national governmental tegulations.If export shipment and I am the Pnmary <br /> Exporter.I cr.by that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify Mat the waste minimization statement identified in 40 CFR 262.27(a)(R I am a Iargequanfity generator)or(b)(if t am a,Wq&an• nerator)is We. <br /> Genemtoe"croes PdntediTyped Name Sign to v,c�m Ga� lea <br /> r 16.Intemaldrial Sh memsp <br /> Imon in U.S. ❑Export from U.S. Port of entryle <br /> F- <br /> a- Transporter sgnaNre(for exports ony): DateleanngU. <br /> 0: 17.TransporterAcluiow edgment of Receipt of Mater a's <br /> UJI <br /> I T er 1 Pdntedli'v Name Signs Month Day Year <br /> a b IM l r <br /> Transoo:f n dfTyped Name Signature Mori Day Aar <br /> is".Discrepapry (/ v - <br /> 18a.Discrepancy Indication Space Eltf � <br /> Quactiy ElT/pe U Residuo ❑PaNal Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> �. 186.Alfemate Fau6y for Generator] U.S.EPA ID Number <br /> ..i <br /> IK( <br /> u_ Facilitys Phone: <br /> uj 18e.SigInalure ofAttemate Facility(or Generate R4onth Day Year <br /> �S <br /> u19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and r&-yciing systems) <br /> Gll1 ml 2. 3. 4. <br /> 120.D09Mfed FaChtyIOwner va Operator.Certifigh'on of receipt of hazardous materials covered by the manifestj pt as rated in Item 18a <br /> edTyped Printamp <br /> `` Si' z M nth Day fear <br /> f,(,t ��►1f>y ( I n \ %% < < 1 nt �c --LA In <br /> Ff'1�)°�' �� rus editions are obsolete. DES A D FACILITY TO DESTINATION STATE(IF REQUIRED) <br />