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Sst- SK SHIP# 2296X5,595 Please print or type. Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page of 3.Fergec� Resppn�e Pgge� 4.Manifest Trackin Number WASTE MANIFEST CAI-203 195294 . r� ` - !SS 0071 7167 SKS 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) `� efv�c f�1: Rl t iter• ffn Co 502- N Fl and Rd I.-I NDEN CA 95236--9455 Generator's�Prhoone: R gy22-4Si, -'88 7- 1*1172 6.Tr t 3_t f C;pm t'oL Est tf � f�i U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number fiLEAN HARBORS ENV SVC INC. fir4 11 @393222`- B.Designated Facility Name and Site Address CLEAN HARBORS ENV I RONMEN t AL SERVICES, IN U.S.EPA ID Number 2247 8 H s GHlr AY `tr 1 i<Ii�BF�t..l. � N� E93.4 Nk X08--2 35--401 "I"D98'?72"3 U-3, Facility's Phone: 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number; 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Quantify Wt./Vol. cY X 1. UN1.21531 WA,3,TE PAINT, 39 0 111 700 F4ZIK D001 O DGS-- 2.13 W z z. uu c� 3. 4. 14. �Special Handling Instructions and Additional Information 9 3D t KP 81286264,:"M64 t.;`)'c-'i4}fit%} `s►a. 66tt I s r-RG'li1 6A 24HEMERufiNCY#810--468-l't760- CC I/SKi FI-Contract retained NY Benerator cortfEArs .4 en-y a1�;,:hori;p� an initial tt~�Ir€soor�ter to add tir° substitute additional tr•�iTtta�3Cfrter"'s ort aenera�. or" s bph alf. 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,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 Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b) if I am a small quantity generator)is-true. Generator,;/Offemr's-PdntedlTyped Name Signature Month Day Year J 16.International Shipments i ❑Import to U.S. ❑Export from U.S. Port ofentrylexit ? Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials LU Transporter 1 PrintedlTyped Name Signature Month Day Year O 0. co,Transporter 2 PrintpolTyped Name Signature Month Day Year 0. 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type yp El Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number U 1 Facility's Phone: urnam T LOU W 18c.Signature of Alternate Facility(or Generator) Month Day Year a Z as19.Hazardous Waste Report Management Method Codes(i.e.,codes for haz LLIa 1. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardou materialserect by the Alest e a n tem 18a Printedlfyped Name S Slur Month Day Year EP F,oXrr}8ZQ0 (�2ev,�2�17,) ,reyiouseditionsareobsolete. GENERATOR'S INITIAL COPY d d'�CSE.+.°a rfDjtf 3G;kT�.._ .9