Laserfiche WebLink
11311) Sul y pit <br />Please print or type. (Form desioned for use on elite (12.n8rhl tvnf.,wdtpr I <br />11 <br />-gg, <br />s edivorts are obsolete. DESIGNATED FACILITY TO GENERATOR STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS 1. Generator ID Number Z- I) <br />*U laf 1 'If J!r <br />CALOO JFE�yft eft <br />I <br />4. Manif t T <br />es racking Number <br />WASTE MANIFEST <br />ind =nt <br />006193E;'r"-"' <br />SKS <br />Tgn—er&rs GWe- a Mailing Address Generator's than mailing address) <br />Masouite Cor-paratiot <br />AS W Stotts r4ye <br />STUCHETON CA <br />Generator's Phone: N9-470-3215 <br />6_WT-V-'rffAFe6Y,qTEKej <br />U.S. EPA ID Number <br />7. Transporter 2 Company Name <br />CLEAN HAR BOR9 ENVIRO NWINTAt- SVC IWC, <br />U.S. EPA ID Number <br />ft <br />MAN3932PP-510 <br />8. Designated Facility Nam and Site Address CLEAN HARBORS GRASSY MOUNTAIN <br />U.S. EPA ID Number <br />3' MILES EAST, 7 141LES NORTIi KNGLLS EXIT <br />41s UFF I- bra <br />KNOU <br />Lr LIT 84083 <br />Faci!il (a Phone: <br />9b. U.S. DOT Description (including Proper Shipping Nam, Hazard Class, 10 Number, <br />10. Containers <br />11. Total <br />12. Unit <br />HM <br />and PaftV Group (If any)) <br />Quantity <br />VAJV01, <br />13. Waste Codes <br />No. <br />Type <br />I <br />Ix <br />"NOWE MIN KRA 14�214RDGW, WASTE L160102 <br />134 <br />0 <br />(01-1-Y MITER), WA ­ <br />160 <br />Uj <br />3. <br />4 <br />14. S f Handing Ins sand Addit oral info don°:i f; f aT <br />i A 4 790 <br />24 MR EMERGENCY t SK TFT) <br />SEE,:A° CWT <br />15. GENERATOFV&'OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above <br />, <br />by the proper shipping name, and are classified, packaged, <br />marked and labeled1placarded, and are in all fespects, in proper condition for transport according to applicable international and national governmental regulations. If export sNpment and I am the Primary <br />Exporter, I certify that the contents of this corlsignment conform to the terms of the attached EPA Acknowledgment of Consent <br />— I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b 2frL generator) is hle. <br />�) a�ll quantity <br />9"rators/Offerors Printed[Typed Narnlit_ S <br />th Day Year <br />B <br />it <br />16. International Shrprnerft <br />El I to U.S. LJ Export from U.S. Port <br />of entryfaxit: <br />Transporter signature (for exports only k Date leaving U.S.: <br />171T"Ad=WedgimtofReci0ofMaterials <br />1 Signatur <br />Month) Ye <br />Day ar <br />14,A <br />T. 2 NaffW' <br />Month Day Year <br />18. Discrepancy <br />ltla. Discrapastcy Indication Space ❑ Quantity 0 Type El Residue <br />❑ P.1.1 Rejection <br />0 Full Rejection <br />18b. Aftemater Facility (or Generator) Manifest Reference Number: <br />U.S, EPA 10 NLffnber <br />Facility's Phone: <br />Uj <br />I k. Signature —ofAftemate Facility (or Generalor) <br />Month Day Year <br />Z <br />52 <br />19. Hazardous West- Report M"ement Method Codes (i.e., codes for hazardous waste treatment disposal, and recycling systems) <br />2 3. <br />47 <br />20. De4named Fadly Owner or Operator: Cedicoon of receipt of hambils, maters owered by ft marift eltollipt as ndad in Rom 18a <br />Pm,I YPOO Name <br />IcyYear <br />-gg, <br />s edivorts are obsolete. DESIGNATED FACILITY TO GENERATOR STATE (IF REQUIRED) <br />