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Please RN or type.{Foran des nodi for use on elite 112-piichj . :j ZQ 0/ SG PPW 10/10!2017 FormAppPoved;OMB No.205UO39 <br /> UNIFORM HAZARDOUS 1.Generathr ID Number 2.Page 1 of 3 E Phom .1Nan�Fast TraakQ11fa umber <br /> WASTEmiFEST C A L 0 0 0 3 5 9 IL 0 2 3 ts' �3718 98398 FLE <br /> 5: Address crane d I marling ass) <br /> 2526 W.Washington Street 2526 W Washin0an Street <br /> Stockton-CA 95203 5tackton,CA 95203 <br /> Ge,era1or'a Maw(2091320-3714 AT NJesse leWS <br /> raruaporler 1 pang U.S.EPA ID Nurnber <br /> 7.Transporter 2 C ny Name ' U.S.EPA ID Number <br /> a. eslgrtated Fadlty Name and Site Address U.S.EPA ID Number <br /> Glean Harbors Buttornrillow LLC <br /> 2500 West Lokern Road 4 A 0 9 9 0 6 7 5 2 7 S <br /> Buttomlrillow.CA 93206 <br /> Faciif s Phone: !6611762-6200 <br /> ga, 913,U.S.DOT Description(Including Proper Shipping Name,Hazard Class,ID Nurnber, 10.Containers11.Total 12.Unit <br /> HM and Packing Group(if any)) NO. Type Quantity M./Vol. 13_Waste Codes <br /> tNON-RCRA HAZARDOUS WASTE,SOLIDS,(FLY ASH) 5Ti f <br /> o _....__;.-.- <br /> Z 2. <br /> C i <br /> 3. <br /> 4. # <br /> s <br /> ¢ p }{gn rrdions and Additional lnbrmalion <br /> 11 SGZi69� 3D <br /> 15, GENERATOR'SIOFFEROR'S CERTIFICATION. I hereby declare that the contents of this consignnenl are fully and accurately described above by the proper shipping name,and are dasMiled,packaged, <br /> marked end labetedlplacarded,and are in all respects in proper coWtion fortransport according to applicable intBmagonel and national governmental regulations.If export shipment and I am the Primary <br /> ExWor,I carlify that the contents of this consignment conform to the terms of the attached EPAAdknowledgnent of Consent <br /> 100*that the waste mnim¢alion statement(dangled in 40 CFR 262,27(a)(If I am a large quantily generator)or(b)(if I am a small guaniity generator)is true, <br /> PrintedlTyped Nam Swalure Wth DN Year <br /> .r 18,International$hlprr4nts <br /> ❑Import icU.S. ❑Export from U.S. Po ent !exit: <br /> Transporter sionsture ft expqrts ony Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of ReoW of Materials <br /> raneoorier 1 ypd Nam 5 MWI)l y Yew <br /> & 14 N �p Gr r [K 1 1)A A4 A I �_j I Tr4ak tar Signature. J. ear <br /> 10-Discrepancy <br /> I Be.Disaepancy Indication Space ❑ Quantity ❑Type Residue ❑Partw Rejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> a <br /> w Facili s Phone: <br /> W Signature ofAlteinata Fadhly(o€Gonerakri Month Day Year <br /> Z <br /> 19.Hazardous Waste Repon Management Method Codes Ike.,codes for hazardous waste trestmerl,disposal,and recycling systems) <br /> c 1. Hi32 2. 3 a <br /> 20 Designated Fadlity Owner or Operator:Certification of receipt of havedous materials covered by the manifest except as Mad In Item 18a <br /> PrinhndrTyped Name Signature Mak Day YOM <br /> loy 106, 1 IO <br /> EPA For � f �btl�S�i i � � g� �9igi25 for and will acc apt the waste t4ege"IFAMIMATORWILITY TO DESTINATION STATE()F REQUIRED) w <br />