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Zoe i�7�9/3s SC PPw i0,�10l2017 <br /> Please print or type,(Form designed for use on elite(12-pitch)typewriter,) Form AplproviDd.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number z.Page 1 of 3 Emergency Response Phone 4.Manifest Tracking umber i Ee <br /> WASTE MANIFEST GAL 0 0 0 3 5 81 0 2 1 (800)483718 11 FL <br /> ��F}apls I� lAddraas rienera s Site Addm%t6 ddfaronl than marling 6ddrfsat <br /> 2526 W.Washington Street 2526 W Was-hin;~tcn Strut <br /> Stockton.CA 95203 Srocmon,CA 95203 <br /> Getwala'sPhone:(2091320-3714 ATIH.Jesse Lewis <br /> 1 U.S.EPA ID Number <br /> 7.Transporter Name U.S.EPA 10 Number <br /> 8.Deslgnated aclfity Name acrd Site Address U,S.EPA ID Number <br /> Clean H arbors Suttonwiilow LLC GAD 9 8 0 8 7 5 2 7 6 <br /> 2500 West Lokern Road <br /> Btittonwillow.CA 93206 <br /> Facility's Phone: (661)7'62-6200 <br /> 9a. 9b.U.S.DOT Description(Including Proper Shipping Name,Hazard Class.ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packig Group IK any)) No, Type Quantity W1110. <br /> 1-NON-KRA HAZARDOUS WASTE,SOLIDS,(FLY ASH) 571 <br /> b <br /> a <br /> T f7,�( <br /> z2 <br /> L <br /> t <br /> 3. <br /> 4. <br /> i <br /> 14.. .LFlanditt9rr39drons anditional Information <br /> 15. GENERATORBfOFFEROR'8 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 Iabeledlplararded,and are in all respects In proper condition for bansport according to applicable international and national govemmenml regulations.If export shipment and I am the Primary <br /> Exporter,I certify[het the contents of this consignment conform to the terms of the attached EPAAdroowledgment of Consent. <br /> I oer*that the waste minimization statement identified in 40 CFR 262.27(a)(f i am a large quantity generator)or(b)(if i am a small quandly gerneralor)is true. <br /> GeoeraluesIOMMt yped Name bVneiturs ear <br /> r5 M <br /> J 16. <br /> ❑Intpal to U'S. ❑Export frau U.S. PA of Melt- — --- — -- ----..._._..------ - <br /> T Data kw±p U.S.: <br /> 17.TransporlerAcfoiawledgnent of Rec*t of Materiels <br /> A� tansparter y Year <br /> on y wail d <br /> Transporter 2 PtftUyped Name rAgrialure win Day Tear <br /> 18.Discrepancy <br /> 18a Discrepancy Indication Space O Quantity ❑Type ❑Residue ❑Partial Rejection ❑Fuli Rejection <br /> Manifest Rafemnce Number: <br /> I Bb,A1[emate Facility(of Generator) U.S.EPA ID Number <br /> J_ <br /> Fadlh Phone: <br /> 1ac,Signature ofAlternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Repot Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1' H132 <br /> 20.Designated Fadtigr Owner or Operator.Cortlixalion of receipt of hazardous materials covered by the mantl st except as noted in Item 18a <br /> P yw S[gnatre Mwdh Year <br /> �s u s u,; o Ob Zo <br /> EPA F,%can ti700.7�JR r 3-05} P ious editions, obsolete 1t1TY TO DESTINATION STATE(IF REQUIRED) <br /> ns 5rtt�iie appropna`Te perinds for and will accept the waste the Tenet u" <br />