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Please print or type. Form Approved,dMB No,2050-0039 <br /> 1,Generator ID Number 2.Page 1 of 3. me n R s se Ph. <br /> 7o06687 <br /> Manifest Tracking Number <br /> ur�iarilM FIAZARI]DUS � + s ,� ,N. w a. y $KS <br /> WASTE MANIFEST <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> 1603 S B St 'Vt <br /> Generator's Phone; <br /> 6. <br /> TIN °r `1 ° n Yea�°�:,#�G I N U.S.EPA ID Number i X ROOOOB 1205 <br /> 7.Transporter 2 Company Maine U.S.EPA ID Number <br /> CLEAN HARBORS ENVIRONWNTAL SVC INC. KADM328250 <br /> 8.Designated Facility Name and Site Address I HARBORS PAM JUSE U,S.EPA ID Number <br /> 1021 BEINRYF3119fl ROAD <br /> SAN Ji cA 95133 <br /> Facility's Phene: <br /> 9a, 9b,U.S,DDT Description(Including Proper Shipping Name,Hazard Class,ID Number, 19.Containers i1,Tota] 12.Unit <br /> HM and Packing Group(if any)) No. Type quantity Wi.lVol, 13.Waste Codes <br /> X 1. N9 A3r7 HAZAMMUSWi SOLID, I .& DF q <br /> 1'5 ;� 00IMI <br /> f ry CAKM {g i 14B171 <br /> ii <br /> Lu 2, NIM RGRA HAZARDOUS WASTE SOLIDS fj Dm <br /> 3. <br /> 4. <br /> 14.Special Hsndlirig_1rstructlons and Addltlonal Information TEDpSJ 7647,598:1 Cr 212 CBC-;' <br /> a F i � .13CY8 - i ,ta,M. ' s a I'w l"Cr .,- f � .r r.^t r alned-Dy pnewa <br /> 15. GEN ERATO,_ OFFEIZOR'S CERTIFICATION: I hereby declare that the contents cf this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and fabaledlplacarded,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 eomardi of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified In 46 CFR 262,27(a)(if I am a large quantity generator)or(b)(If I am a small quantity generator)is true. <br /> Generator'sfOfferor's PrintedlTyp(gd Name Signature1 F Month Day. Year <br /> �' jaw-i'.I J/� I J] w.�✓ ` }' l�� C I �'�-' ��� 1 r !� �. ry.(.'. <br /> 16.International Shipments <br /> El Import to U.S. ❑Export from U.S. Port of entryfoxit <br /> Transporter signature(far exports only): Bate leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> Transporter 1 Printedl�ped Name Signature .'"fir 7 Month Day Year <br /> LL <br /> Transporter 2,Printedllyped'IVame Signature IW° Month Day' ` Year <br /> r _ � <br /> 18.Discrepancy <br /> I Be Discrepancy Indication Space ❑ Quantic Type Residue <br /> Quantity ❑ yp ❑ ❑Partial Rejocfion ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Altemale Facility(or Generator) US,EPA ID Number <br /> U <br /> Facility's Phone: <br /> � 180.Signature of Alternate Facility(of Generator) Month Day Year <br /> di <br /> 19.hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste(reatment,disposal,and recycling systems} <br /> M 1. 2. <br /> 20.Designated Facility Owner or Operator:Coffflcatian of receipt of hazardous materials covered by the manifest except as rated in Item 18a <br /> PrintedlTyped Name Signature Month Day Year <br /> EPA Form 57x0-22�a(Rev.12317 Previous editi ns are obsolete. c,• GENERATOR'S INITIAL COPY <br />