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SC PPW 11/21/2015 <br /> Please print or",(Form diamigned for use on elite(12-.pitch)f iter.) Form Approved.OMB No.2050 0438 <br /> UNIFORM MANIFEST S �L 0 A 0 3 5 910 2 2.�ge 1 of 3.fib9 Y h a.Ma1510'P4938 <br /> ifest TracOkrng N�grb�9 3 8 FL E <br /> WASTE MANIFEST (��+1 Z !7 <br /> } Generatar's Me Ad cess(il dlflerenl Ilan rnalling addrassl <br /> 2526 W.Washirgpzm Street 17525 W Washi l an l <br /> lQtnpktnn rA Qgi?iMi SWddon.CA 95243 <br /> V WY�4►V e..W Y ViY V <br /> Generatast mrca: f2O91320-3714 ATTNJesse Lewis <br /> r <br /> Yr <br /> US:EPA 10 Number <br /> GSA�D4U <br /> 7.1'rsnspnrter 2 Name US-EPA ID Number <br /> S.Designated Fad*Name mW Site Address U.S.EPA ID Number <br /> Clean Harbors @uttonwWorw LLC CAD 9 6 0 6 7 5 2 7 6 <br /> 2500 West Lokelrn Road <br /> Buttonwiilow.CA 93206 <br /> Face - Phone: 16611762.6200 <br /> ga. 9b.U.S.DOT Description(ndudng Proper Shipping Name,Hazard Class,11)Number, 10 Containers 11.Total 12.Unit <br /> HM and Paddng Group(if any)} No. Type Quantity WIM, 13.Waste Ccdes <br /> ' NON-ROM HAZARDOUS WASTE,SOLIDS,(FLY ASH) 571 <br /> Z 2 i <br /> cW7 1 � <br /> 3. <br /> r <br /> 4 <br /> i <br /> I <br /> 14.Spoctal Handing InsVUCliorm and AddltionW InlQr mil n <br /> 1.CH6417538 <br /> 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, <br /> marked and nbeledlplararded,and are In all respects in proper condition for transport according to applicable inbernstional and national governmental regulations If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAckrowledgmem of Consent <br /> I certify that the waste minimization statement identified m 40 CFR 262.27(a)(111 am a large quantity generator)or(b)`it 1 am a small quantity generator)is true. <br /> Hera s fin yped Nan* Nywre 0571113 5—fly-75—F <br /> �+ 16.International Shi4enis <br /> I- ❑Import to U.S. ❑Bpd from U,S AofentrAit <br /> Z Transporter s' nakre fore its on : Date leavi U.S.: <br /> 17.Tmnspocter Acknowledgment of Receipt of Materials <br /> Tfanspotter 1.Pyped Name Skilmiure Year <br /> CL e <br /> TransiMer 2 Pfintudrryped Name signiature Kxm Day Year <br /> 16.Discrepancy r <br /> 18a Discrepancy In&_-alion Spars ElII��Quaray L_J Type ❑Residue Ll Partial Rejection ❑Full Rejection <br /> h1awfaO Refervkm Number. <br /> 111h-AtternateFacility(or Generator) U.S EPAIDNumber <br /> V <br /> Q <br /> Fadrrr s Phm: <br /> B 18c S no aos,IA?err�a>r Facikry{rirt^,gaiararwl Month Day Vem <br /> a <br /> Y <br /> 19 Hazardous Waste Report Management Method Codes(0,codes for hazardous waste treatment,disposal,and rrWrmg sysleir s) <br /> 0 1' H132 <br /> 20.Designated Facility Owner or Operator;Certifrcetlon of receipt of hazardous materials covered by The manifest except as rioted In Item 18a <br /> Prinr'LdlTyped Name Sk nature Month Roy Year <br /> 1 &6 120 <br /> EPA Farm 87f10-22(Rev: 3.05) Rre sous edibons Ord obsolete., !CITY TO DESTINATION STATE(IF REQUIRED) F <br /> clean Harbgrs has the appropnata permits for and will actept the waste a g..,VW�#�Pi l <br />