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SHTr'1! ?1'll-' 01--- <br /> Please print d I"(Fpm,d 1.0 lar use on euro(12—Pitch) writor o 0 <br /> 2.Popo ld ]Emq�p4 f{ayq we�Ir�yArgr'iM_.fjrlE.!x,.2iYl+ " <br /> UNIFORM HAZARDOUS 1W�wr+Mr le Nu�nbat CAL OIOL7013]!.'.�-1.�. ] I—t5101f)T-46f5-1/60 i�NunGr <br /> WASTE MANIFEST O O 5 J L 8 O 1 •7 IS�(Q <br /> S Gana3a Name—Harrup Ade,ass GenenWY+57b Mdross(II dXWy--.— <br /> D nuarg aad„tih V 1 / v.`aI <br /> ad Of Calif`—nia <br /> 1050 Diamond Somth Si: <br /> STOCKTON CA '?. .05--702'0 <br /> Ganerawr�,Pnnoe: 209--601-8720 <br /> v1t�c-KL��MnaN <br /> o� � U.S.EPAiD Ilun4n <br /> `.arit-teff SYSTEMS, INC. Txcs>,0008120 _ <br /> r.Trans;,a erg c--T—y Name - <br /> U 5.EPA IO Hunber <br /> a.0os(pnatM FaWiry Narne and Srte Addra+s CLERK HARBORS ARAGONITE Ltd <br /> U.S.EP4 tU rwmoer �i<+ <br /> 11600 NORTH APTUS ROAD <br /> AP,A30NITE OT 04029 <br /> 435–BD4-0100 ' <br /> !rTD9815521' <br /> FauliNs Ph—. <br /> z r <br /> 9a. Bb.U.S.DOT Descdptlon(ndudmg Proper Stopping Name,HezaN pas$,ID Number, I to.contanaro 11.Told 12.UM t1 Waste s ;. - <br /> Ha1 and Packing Group(if eny)l N. j Tyle a—"V WI fJd. <br /> ' UN1888, WASTE CHLOROFORM t4IXTURE, F. 1 1IF � F' D0c2 2.11 <br /> PG T I I s tom•. r_,, <br /> z <br /> W <br /> C� <br /> i <br /> 4 <br /> TSD.•AG 70*2BF-356 D117225 <br /> 1 1ER6#151 NO <br /> 24 NR EME4GENCY #1-800-4CS-17Erd (.SK / TFI) <br /> �= r T <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,arc are dassited,pacxagW, <br /> marked and labelediplararded.and are in all respects in pr nditon for transport acoordng to applicable international and nalimal governmental regulations.It export shipment and 1 am t-*Primary <br /> Exporter,1 certify that the contents of this con si 7 the tears of the attached EPAAcknowledgment of Consent. <br /> I certify that ft waste minim¢atfon statement tfi., m o FR 262.27(a)(d 1 am a large quantitygenerator)or(b)(if 1 am a small quantity generator)is We. <br /> ratoes'OReror's Pnnted/Typed No Sigralure <br /> IAcnth Gay Yea <br /> www - <br /> 6.International Shipments0 import to U.S. <br /> nlpo ❑Export from V-S. Pod of entrylexiC <br /> Transporter signature(for evens only): Dale leaving U.S.: <br /> ar 17 TransportarArknowfedgment of Receipt of Materials <br /> j�2 Transporter 1 Printed,Typed Name rt. Signature Mortl Day Y;,ar <br /> 00 <br /> Q er 2 Printedlf Name Sign Mcniihi Day Year <br /> s Z. <br /> A 1Atlfcr�.n—, <br /> 18a.Discrepancy Indication Space Ej <br /> Quantity El Type esldue ❑Partial Refection Full Reteclion <br /> Manifest Reference Number. <br /> It 18b.Aitemate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> LL Facility's Ptume: <br /> w 18c.Signature ofAilernate Facility(Dr Generator) Month Day Year <br /> z <br /> 19.Hazardous Waste Report Management Method Cafes(Le,codes for hazardous waste treatment,disposal,and recycling systems? <br /> t 2. 3. 4. <br /> 20.Designated FactI4 Owner or Operator.Ceftfcation of receipt of hazardous malerlals cevered by the manifest except as noted in Item 18a <br /> Prtn�l��lfyped Namw i _-, % A,.,., —., '&'grHtu` AC-b /1 t�ith Day Year <br /> wzyll _ '{(/ fit, , <br /> EPA FQm)87122(Rev.3 0� Previous editions are obsolete. �, bESIGNATED FACILITYTO DESTINATION STATE(IF REQUIRED) <br />