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js Xf�172z 136= YK& YE5-3z 1`P6 <br /> Ploasepdnt or typo.(Form designM forum on eli@(12-pi1a1)typewdteq I 015gQ703 9CPPW 10/10/2017 Form Approved.OMB No.20500039 <br /> UNIFORM HAZARDOUS I TGMa21IN ID Number 2.Page l of 3 E.Earqy Response Nom 4.MdniML Tracking Number <br /> �W¢AA�SdTpEyMANNnIFFEST Ere, <br /> 0 0 0 3 5 91 0 2 1 (9001493-3716 FLE <br /> 6 UI[SS wl.Ere,PaamsIt <br /> Generdfoh SIId Atltlress(ifGiRerenl Nan nailing atltlressl <br /> 2526 W.Washington Street 2526 W Washinkton Street <br /> Staukmn.CA 95203 Stodnn.CA 95203 <br /> Gmewtora Plwnea2091320-3714 ATIENJesse Lewis <br /> 6.Trm,ftrtpony Name LLS.EPAID Numcer <br /> 0-5 <br /> irznslMwlLanpdnV Na <br /> SFGaWorm, <br /> d�/S93 3 <br /> 8.Dm9nawo Facility Name aro SUeMmaa US EPAID Nnmcer <br /> Clean Harbors Buthaneillow LLC <br /> 22500 West Lokpmyy Road CAD990675276 <br /> Bu=nwilow.CA(66117628200 <br /> Facility's Phone: <br /> ga, 9b Us.DDT Desonplim(indWn,Racer SM1lpprg Nam,Hamm Gam,ID Number, 10.Carol am f1.ioMl 11 <br /> .Unll I3.Waste Cotler <br /> HM antl Paoan9Gmu4(Rany)) No. TYPe Qu anAry WI Vol <br /> 1. (ARSENIC.CH MIBbp, ! <br /> 0 x S.PG III,BOTTOM ASH) 571 <br /> = z. <br /> 3. <br /> q p�y^o,y��gg aa 9955ryry <br /> 1 SI:Ya.J4�alrcgons aMNMiUoreLlpfpmaGM <br /> 15. GEHEgATdlabo FFEROR'S CEgiIFIDpTIDX: lbezbytletlare Mal Ne mnten6 of Nis mnvgnmenl are fully and aovralelYtlrscriped above by NepropersM1ippiywm,anAareniaroetl,pacNar, <br /> marketl "bolkNplaWrtl J,antl Grein all resp 15mpre�rmndtion MYanspAl aanOingbappLwple lnlemeAonalaM ratlonal gGva'nmenfel regulalrora.If espwl sM1gmenlaMlam Ne Primary <br /> nm <br /> E�pvlen!tlM stem iml olN matuenv innfwm IOMe 27(ao(Medllewb eEPAtUgenetlor)ol(b Chian <br /> ceNfi WIIMx'aale mTimleaAm srg4men14enMiM In 4o LFR 162YT(aj(M amaWrye puantitygennounjw(b)(ill amasmall quanAygerprtlnr)iS bue. <br /> n 1}N1 a gnu ureon aY .1 <br /> J 16. vy <br /> Inlemaf al SM1ipm 15 / <br /> i ❑Importto116. ❑bane nom US. P of enl wit. <br /> Ton vers nature(area Dmlean U.S.: - <br /> w 1T.irenspMer motor Maferwis <br /> Tmnspinwl and Ym Name 9 Nre <br /> ar <br /> i(Sn�, ey lel <br /> i iranspoNer3PtlncerNyp _ ynawre o N Uay Year <br /> f <br /> ♦I 18.Diswepan, <br /> 18e.Disaeparrcy lntliplron Spare ❑ Nanny ❑Tpa ❑Rmkue El Pam roan, ❑Full Rejedgn <br /> Mamfesl Rerererrce Number. <br /> 18b.A1@mate Faaliry(w Gaiemtw) US.EPAID Number <br /> J <br /> U <br /> LLFao aWgne' <br /> . <br /> Q18a.SryreNre MPJMmareFaality for Ganwanor) <br /> Mont Day Year <br /> 2 <br /> y19.HauMws WaSle Repan Mdnagemenr M¢MN LCEes(ie..mtles fwM1azallous wa5le lreaNem tlispoml,antl resyghg systems) <br /> W I <br /> 0 H132 2' <br /> 120DograladFmlt0wnerorOperator.CeVBT onofmeiptofhazardommaterIsmveretlbyIbema6,1oeeceWnnatlinlMw18a <br /> yp <br /> PtlnleMM Na J 1gignaryre M.m Day Year <br /> a4 ipo�a�ra �p `'1 -A L1 <br /> EPA Fo���i ill gr91�`��reHnaaPpe�"1{tids for and will aareet the waste the seneA{Igl%f4ILITY TO DESTINATION STATE(IF REQUIRED) <br />