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o?zl- Please print or type.{Form designed for use on elite(12-pitch)typewriter.) SIG PPW WiOl20V Foran Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1,Generator 1D Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number I F E: WASTE MANIFEST FL 5.Generator's Name and Mailing Address Gee or ite dress if r erent than mailing address) DTE Stockton LLC 2526 W.WashkgPn Street 2526 W Washinj%Dn Street Stockton:CA 65203 Srotidkton,CA 95:'.03 Generator's Phone: Transporter 1 mpany Namfe U.S.EPA ID Number It 0 7.Transporter 2 Company Name U.S.EPA ID Number B.Designated Facility Name and Site Address U.S.EPA ID Number Clean H arbors Buttonwillow LLC CAD 9$0 6 7 5 2 7 6 2500 West Loke n Road FRN""How_CA 93206 f1861:111 76"2" 9a. 9b.U.S.OOT Description(including Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity W1.Nol. 1.HON-RCRA HAZARDOUS WASTE.SOLIDS,(FLY ASH) 40700 o Q,F W a: 2. ui 3. 4. 14.Special Handling Instructions and Additional Information i_CE64IL75315 15. GENERATOR'S10FFEROR'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 labeledlptacarded,and are in all respects in proper condition for transport according to applicable international and nationa governmental regulations.If export shipment and I am the Primary + Exporter,I certify that the contents of this consignment conform to the terns 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 1 am a small quantity generator)is true. Genera or rs rintedlTyped Name SignatureMonthay ear �_ / _r 16.International Shiprf ants F; ❑Impod'to U.S. ❑Export from U.S. P00of entr�(!XA: ?= Trans orter si nature for ex ris only): Date leaving U.S.: ui 17.Transporter A owledgment of a of Materials F Trensporter 1ITy d Nam SUM morth Day Year a a zTransporter 2 Printed/Typed Name Signature Month Day 7ar F� 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b Alternate Facility(or Generator) U.S.EPA ID Number C.1 u• Facility's Phone: uj 18c.Signature of Alternate Facility(or Generator) Y Month Da Year :• ui19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) [i 1. 2. 3. 4, Hi32 20.Designated Facility Owner or Operator:Cerdfication of receipt of hazardous materials covered by the manifest except as noted+n Item 1 f a Pri ypedNae M nth Day Year G" EPA For 00-22(Rev. -05) Previous editions are obsolete. ACILITV TO DESTINATION STATE(IF REQUIP ED) clean Harbors has the appropriate permits ler and will weep the waste the generator is Fhippittrg.