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V16Z4 7/4 I //0 , # 112 L5A5V41711e � rPlellr <br /> FVease. rint ortype, (Forrti designed for use on elite (12-pitch) typewriter,) 1 i 1034924G"01 SC ppW 5,!30/2017 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2. Pae 1 of 3. Emergency Res Form Approved, OMB No, 2050-CO39 <br /> 9 rg y ponsa Phone 4: Ma Ifest T ckfn Number <br /> WASTE MANIFEST A . R p 0 g 2s 1 soo 4s31� t 1 . ( 02575 FLE <br /> 5: Generators Name and Mating Address Generator s Site Address (JI' different than mailing address) <br /> Hl Heinz I <br /> 67.55 G E bixon Street. . + <br /> It <br /> Strioiit~on_ '9fs20�G : ,:,. . , . SAME <br /> deneralV$ Phone: ` .t209) 932j5771 <br /> 6. ransporter Company Name <br /> Clean Harbors Environmental Services, Inc. U.S. EPA 1D Number <br /> 7. Trensporter2 Compan Name <br /> MA : D03932225 .0 <br /> U.S, EPA ID Number <br /> 8. Designated Facility Name and Site Address <br /> U.S. EPA ID Number <br /> Clean Harbors AlrWonite LLC <br /> iiG00- Nort_ hAotus .Road . U1 D 9 t31 5 5 2 3 7 7 <br /> Grantsville. UT84029 , <br /> Facility's Phone: ' <br /> ga, 9b. U,S_ DOT Description (induding Proper Shipping'Name, Hazard pass, ID Number, 10. An <br /> HM and Pack ng G cup (if any)) i1. Total 12. Unit 13, Waste Codas <br /> 1 No. Type Quantity WUVoI. <br /> o . <br /> od UNi�66, WASTE CHLOROFORM SOLUTION . G.i, pG 111 <br /> 00, i .. C. F, . 0 .002 . : . p . <br /> D02 F <br /> Ir, tI <br /> iu I. <br /> 2. <br /> r9 <br /> m 51 <br /> 3. <br /> 4. <br /> t <br /> 14. Special Handling Instructions and Additional Information <br /> l : CH7 92 47 9 ERGS 151 1X20 FLEETS 5234 <br /> 15, GEF)ERATOR'SlOFFEROR'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, <br /> marked and tabeledlplacarded, and are in all reSpeGS 1n proper condition for 'Uansport according to applicable international and national governmental regulations. If export shipment and I'am the Primary <br /> i <br /> Exporter, I certily that the contents of this consignment conform to the terms of the attached EPAAcknowledgment 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) ('d I am a small quamity generator) is We <br /> 3eneratorsi0fteror's Pnnad/Typed Name gna re <br /> EDARUEG <br /> °n aY ear <br /> ..+ 16. intemalonal Shipments <br /> f CINS <br /> m F] Import to US. ❑ Export from U.S. fort antrylexl <br /> trans Norsi nature for exports only): <br /> 17. TransporterAcknowiedgment of Receipt of Materials Date leavkr .S.: . <br /> Q; Transporter 1 Printed/lyped Name <br /> ignature 9 ear <br /> am . ERIC .C_AT ELL :.. . -. . .. -- <br /> 1 Transporter2 Printe ama <br /> tg ature07I. : 12 � 17 , ;� <br /> r /� DaY �r 3 <br /> � • G / , <br /> iF . Discrepancy <br /> 18a. Discrepancy Indication Space <br /> ❑ Quantity ❑ Type ❑ Residue ❑ Parlial Re ectfon <br /> ) r ❑ Full Rejection <br /> ib. Alternate Facility (or Generator) Manifest Reference Number: <br /> .r U.S. EPA ID Number <br /> c� <br /> i' <br /> LL4 a <br /> - Fcitit 's Phona; - ' <br /> W 18c . Signature of Alternate Facility (or Gene{ator} <br /> Month Day Year <br /> r' <br /> 13. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> w �,- <br /> o <br /> H040 21 <br /> a1P MR <br /> a. <br /> y <br /> mmImm10. Designated Facility Owner or Operator: Cerlificalion of receipt of hazardous materials covered by their anifest except as notelf in Item 18a <br /> Priniecilfyped Name Sgnature <br /> ( ,e Month D Year <br /> mm P <br /> EPA =Crrn 8700-22 (Rev, 3-05) Previous editions are obsolet . ESQ tta � p <br /> Clean Harbors has the appropriate permits for and will at rept the waste the fen V#P rsTSTi JAJJ'ITY TO DESTINATION STATE (IF REQUIRED) <br />� t <br />