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� <br /> Please print or type. (Form designed for use on elite ( 12-p 6) 160028761.441022 5C PPW 1/2Z/201.10itch) typewriter.) Form Approved. OMB No, 2050-0039 <br /> UNIFORM HAZARDOUS 1 .81"A' 81 <br /> a erat r 1 N m er 2. P ge 1 of 3. ergen Response Phone 4, Maa�nife(sstt Tracking Number <br /> '� q � <br /> WASTE MANIFEST ( Q 2 9 4 8 f8U04�i-3.3718 V J sLrL 1 ( ` � � LE <br /> 5. GraMailing Address Generators Site Address (if different than mail ig address) <br /> 4707 Pacfic Ave 4707 Pacific Ave <br /> Stockton. (;A %201 Stockton.C-A 4520 T <br /> Generators Phone: (9001597"2228 ATTH tare Manaeor <br /> 6. Transporter 1 Companyame U.S. EPA ID Number <br /> dean Harbars Environmental Service, Inc. M A D p 3 9 3 2 2 2 5 0 <br /> 7. Transporter 2 Company Name II U.S. EPA ID Number <br /> B. Designated Facility Name and Site Address U.S. EPA ID Number <br /> Clean Harbors Aragonite LLC <br /> 1.1. 600 North Aptus Road 1U T D 9 81. !i 5 21. 7 7 <br /> Grantsville. UT 84029 <br /> Facilites Phone: (435) 884.8100 <br /> ga. 9b. U.S. DOT Description (including Prcper Shipping Name, hazard Class, ID Number, 10. Containers 11 . "btal 12. Unit 13. Waste Codes <br /> HM and Packing Group (f any)) _ No. Type Quantity Wtivolo <br /> Z 1 . UN3248, WASTE MEDICINE, LIQUID, FLAMMABLE , TOXIC, _ U034 D00i 311 <br /> o X N .O.S., 30 tl6.i), PG !l L d <br /> W 2. UN 03244e WAJgW MFnIr. IRE, 50.LID , T(1Xlt", iN 0;15 a f•). 601 , FNS ! ! U034 31.1. <br /> NIPPON <br /> 3. <br /> E <br /> 4. <br /> 14. Special Handling In and Additional Information { �. 0 •F"FF7 el "173 3 �/� 4/!- , <br /> l . Tar - AEAf1xm ERG#131 fids D P �l 7 <br /> 2 . Tar -- 0EAtvxicr ERG# 151 IX5b P L IeAloI -Y 7.15 <br /> 00 <br /> Joe <br /> 600 <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment ure fully and accurately described above by the (toper shipping name, and are classified, packaged, <br /> marked and labeledrplacarded, and are in all respects in proper condition for transport according to applicaale international and national governmental reculations. If export shipment and I am the Primary <br /> Exporter, I certily that the contents of this c)nsignmeni conform to the terms of the attached EPAAcknowledgment of Consent, <br /> certily that the waste minimization statement identified in 40 CFR 262.27(a) (d I am a large quantity genr:rator) or (b) (if I am a small quantity generator) is true. <br /> Generatof eror'sPrnte (Typed Name bignawria �oOrT-[rayear <br /> 16. International Shipments <br /> ElImp<xEl to U.S. LJ Export from U.S. Port of entry/exit _ <br /> Transporter signature for exports only): Date leaving U.S.: <br /> 17, Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printedrfyped mergaa r - t��ay ear <br /> C' r <br /> a oe 115F 11& <br /> OFF <br /> Transporter 2 PrintedrTyped Name S t8 "U `� Montt Day Year <br /> 18. Discrepancy l�l <br /> 18a. Discrepancy Indication Space EJ Quantity ❑ Type ❑ Residue ❑ Rutial Rejection LJ Full Rejoction <br /> Manifest Reference Number: <br /> 18b, Alternate Facility (or Generator) U.S. ;=PA ID Number <br /> U <br /> Facili s Phone e: �� <br /> UJ 18c. SignaturofAlternate Facility (or Generator Month Day Year <br /> 19, Hazardous Waste Report Management Meth)d Codes (i.e., codes for hazardous waste treatment, disposal; and recycling systems) <br /> 0 1 H040 2. H040 3, 4. <br /> 20, Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> ojj�Printed/Type me � "�� ' � SigrrjntQWZJ* <br /> , �� Morth ��, Year <br /> KL <br /> EPA FormiRan NaeriorOSShas tie appy°iipnaobsolete. .rts for and will aeo+tpt the wa :?!e linehiATPQ <br /> Ili <br /> ITY TO GE5'I INATION STATE (IF REQUIRED) <br />