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25L ~'wig 0141PO 2 2641314-4 7 <br /> Please print or type, Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generalor f Number ����17�� �i � inb��� ,� �w,� �w•��° ���� � t Tracking Number WASTE MANIFEST � S Kao <br /> 5`.Ge�noerallor'sTName and Mailing Addres:s{a�qy M y q o^}%��y Generator's Site Address(If different than malling address) <br /> {1�^�}!0^rr @73 �( B 1 t <br /> p995206-2476 <br /> Generator's PhonoF 3 '�kw�.�4�,�.w81 7 <br /> 3 I <br /> 6.Tr 3tb t N e aY l IR Ia U.S.EPA ID Number <br /> TXR00008 <br /> 7.TransportAr 2 Company Name U.S.EPA ID Number <br /> CLERK HARBORS ENVIRONMENTAL TAL SVS" Iii <br /> 8.Designated Facility Name and Site Address. If11d � I { I�i1� & IN <br /> U.S.EPA ID Number <br /> P-247 8 HIGHWAY 71 V <br /> Facility's Phone:. <br /> �a 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HIM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity WI.IVoI. <br /> W X 1. UNU263w WASTE Nl4i PCY' 11 P x'80_,. F005 000 <br /> Wort D006 212 <br /> Z 2: <br /> LLJ0 <br /> 4. <br /> 14.Special}Ha <br /> n <br /> d <br /> ling Instructions and Additlonal Information ,.1,19D 4 KP • 8`;10 57e CA47954 COG� <br /> 24H ratained by yona ator conforg �Ancy authori .y <br /> OTI initial trai'mmetter to add or substitii additinnal 'fir.,•ns nsalleLs nn ; E0 S bahalf. <br /> 15. GENERATOR'SfOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are ciassi ied,packaged, <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 certify that the contents of this consignment conform to the terms of the attached EPAAcknowlsdgment of Consent. <br /> I certify that the,waste minimization statement identified in 4D CFR 262.27(a)(if I am a large quantity generator)+ t(h)(if Ppm a small quantity generator)isjrue. <br /> Generator "IfErpr's Printed/Typed N m },q Signature Y „,M Month D(+..ia�y j Year <br /> 1/ <br /> Nti SM"• \' Wt ` Ye.,? q,F 3 ,h� <br /> 16.International Shipments ❑ i <br /> y� Import to U.S� � - �❑Export from U.S. Part of entrylexit: <br /> Transporter signature(for exports only): Dale leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> � Trifispo ler 1 PrintoNjy"ad Name Signature • ) � M(onrthy Day Yeal <br /> CL <br /> tP`.. - f M'`'" <br /> Transpvrte`2P)nfedffypedName Signature Month Day Year <br /> ILff <br /> e� <br /> 10.Discrepancy <br /> 18a Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Refection <br /> Manifest Reference Number: <br /> 1 Bb,Alternate Facility(or Generator) U.S.EPA ID Number <br /> Facility's Phone: <br /> Lu 18c Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1. 2, 3. 4. <br /> 20.Designated Facility Owner or Operator:Corti€kation of receipt of hazardous materials covered by the manifest except as noted in Ilem 18a <br /> Printed fTyped Name Signature Month Day Year <br /> EPF )oAf Od! lvl A )1Pe,ious editions are obsolete. GENERATOR'S INITIAL COPY <br />