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'R"088440 SC PPW 31/21,/2035 <br /> Please Iinal or typo.(Form des(nod for use on elite(12-pitch)typewriter.) 4001 Form Approved OMB No.2050-0039 <br /> UNIFORM HAZARDOUS lCle t'ID�''6bb 5 9:10 2 1 of 3. g{gptir yy� 14,ala if tT Oi IN bel 4 0 FLE <br /> WASTE MANIFEST 1 1 4 <br /> 5. Address Generatar's SiiaAddress(i diftaran[than mailing address) <br /> 2526 W.Washington Street 2526 W WashinAtan Street <br /> Stodden.CA 95203 Stacktan.CA 95203 <br /> Generetora Phone:(2091320-3714 AT NJesse Lewis <br /> ianspartur I Nwiny U,S,EPA IA Wrnbar <br /> +<-d0 2-76 <br /> rrarepcidw 2 Company Name U.S.EPA ID Number <br /> 8. ed Fadtily Nntlk@ tr . it0 s U.S.EPA ID Number <br /> Clean Harbors Buaot�wl* ow LLC C A O 9 8 0 6 T 5 2 ;6 <br /> 2500 West Lakem Road <br /> Buttonwillaw.CA 93206 <br /> FaW es Phone: (6611762-6200 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10 Containers 11.Total 12 Unit <br /> HM and Packing Group(it any)) No, Type Ouanlity WtiVol, 13.Wasle Codes <br /> 1. <br /> 0 <br /> LYr <br /> w <br /> 518 7 > <br /> Z 2. <br /> LU <br /> 3. <br /> 3 <br /> 4, <br /> 14.Special Handing Instructions and Addtlional Information <br /> 1_CH6417535 <br /> 15. GENERATOWS10FFEROWS CERTIFICATION: f hereby declare[hat tfie contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national govemmental regulations if export shipment and I am the Primary <br /> Exporter,I certify(rat the conlents of this consignment conform to the terms of the altadwd EPA Acknowledgment of Consent. <br /> 1 cedify Ihal the waste minimization statement identified in Off CFR 262.27(a)(if I am a large quantity generator)or(b){t I am a small quantity generator)is true. <br /> s. a hgna aY <br /> r <br /> J 16.International nts <br /> t` ❑Import 1e U.S. ❑Exporl from U.S. of e-nl exit <br /> z Transporter Signallure{far exports onlvl: Oate leaving U.S_: <br /> W 17,TransporterAc krhowkedgment of Receipt of Motorists <br /> Oi TransfW 1 Prim ypad y 1w <br /> R I�L� <br /> Z Transporter 2 onlediTy me ( ahue en y Yew <br /> f <br /> 18.Oisaepency I ��--77 <br /> 18a.Discrepancy Indication Space ❑ Quantity U Type ElResiduet_.t Partial Rejectiorh <br /> U Full Rejection <br /> Manifest Reference Number: <br /> 18b.A(emate Facility(or Generator) U.S.EPA 11)Number <br /> J <br /> 47' <br /> LL- Facil s Phare: <br /> W 18c.Signature ofA(emale Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> y19.Hazardous Waste Report Management Method Codas(i a.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> O 11. 2 3. 4. <br /> H132 <br /> "'toy Owner or Operator:Cerlificaliun of receipt of hazardous materials covered by the manges)except as noted in Item 1 Ba <br /> ignature _ Month ,ay ear <br /> EPA Form 97022(Rev,3.05) Previous editions are obsolete, 7+� LITY TO DESTINATION STATE IIF REQUIRED) <br /> clean Harbors has the appropiriate permits foF and will aeeept the waste the Sone ��i� <br />