Laserfiche WebLink
+Zoo Sc PPW 11/21!2015 <br /> Please pr+nt or 4W.{Farm designed for use on elite(1241ch)tyipewnler.) Form .OMB Na.2050-0039 <br /> UNIFORM HAZARDOUS 1 1•Generator ID Number 2.page 1 of 3.Emergency Response Phone 14, no 3mtw <br /> WASTE MANIFEST ICAL000359102 1800)48:3-3718 1010274944 FLE <br /> 5. t 4.e fg Address Generalor's Site Address(if different then mailing address) <br /> 2528 W-WashitnMn Street 2526 W Washington Street <br /> Stodctan.CA95203 Stockton.CA 95203 <br /> Generators Phone: (2081320-3714 ATTNiesse Lewis <br /> rartSp w y-"ante. U.S.EPA <br /> �1l)Number <br /> 4 ! i� boli q-lu <br /> 7 Transporter 2 Company Name U.S EPA ID Number <br /> B.Uesignated Facility Name and Site Address U.S.EPA 10 Number <br /> Clean Harbors Buttonwillow LLC GAD 9 8 0 6 7 5 2 7 6 <br /> 2500 WestLokem Road <br /> Buttarrwillow.CA 9320$ <br /> Facili s Phone: (6611762$200 <br /> 9e, 9b.U.S.DOT Desioipfgn(Including Proper Shipping Name,Hazard Class,ID Number, 10 Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13_Waste Codes <br /> No. Type quantity "Not, <br /> 1 R0114CRA HAZARDOUS WAS I E.SOL10S. .rra <br /> Z <br /> LU <br /> 3, <br /> i <br /> 4. <br /> i <br /> 14.Special Handling Instructions and Additional Inlormatton <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 labeledlplacarded,and are in all respects in proper condalon for transport according to applicable international and national governmental regulations if export shipment and I am the Primary <br /> Exporter,I codify that the contents of this consignment cianform to the lerms of the attached EPAAckrlorMedgment of Consent. <br /> I certify that the waste minimization statement identified in Q CFR 262.27(a)(if I am a large quanlfiy generator)or(b)(if I am a small quantity generator)is true <br /> Generator'.. sntu gna ire y ear <br /> .ted `I 10-AAkdWO 10 <br /> -A 16.Inlemational Ship nts <br /> ❑Import to U.S. ❑E pert from U.S P011120TY1041 <br /> Transporter s' na" for ex only): Date lea' U.S.: <br /> W 17 Trarispor1erAdWvv1 dgmnnt ReDeipt of Materials <br /> a Transpa4a nted ped —ffon y ear <br /> �Z cob �� `/ � <br /> Transporter 2 Printed[Typed Name Signature Month Day Year <br /> 18,Discrepancy <br /> i <br /> 18a.Discrepancy Indication Spate ❑ quantity ❑Type 1:1 Residue �-J Partial Re*1on ❑Full Rejection <br /> Manifest 12sfe4e m Number. <br /> 1a Alternate Factfity(or Generator) U S.EPA ID Number <br /> U <br /> LL Famlil'sPhorte; <br /> 130 S p+wttae rrf AJtermate FActi ty(or Generator) Mwdh Day Year <br /> 4 <br /> 2 <br /> 19 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste heahrent,disposal.and recycling systems) <br /> LU 1 H132 2. 3. a. <br /> 20.Designated Facifily Owner or Operator:Codification of receipt of hazardous materials covered by the manifest except as noted in Item 1 Ba <br /> Prtntedlfyped Name Signature nth Day Year <br /> L{ L 7 1'LO <br /> EPA Fom;8700-22(Rev, Pfayimis editions are obsolete., W#ILITY TO DESTINATION STATE{1F REQUIRED) t <br /> Glean l*biers has t tT a appropriate permits for and will accept the waste the genft i <br />