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Please pdnl or. .(Form det*Vd for use on elite 12 ftch I11'1^3-5, SC PPW 10/10/2017 <br /> yf er.) �t7Form A222d,OMB No.2050-OD39 <br /> UNIFORM HAZARDOUS i•Generator ID Number 2.Page 1 of 3.Emergency Response Phone0.,Manifest Tracking Nurnber <br /> WASTE MANIFEST CAL 0 0 0 3 5 91 0 2 1 (9001 48 33 71$ FLE <br /> S' 83999 <br /> Gererelo s Via Miss I di rent ifien malwV address) <br /> 2526 W_Washington Street W <br /> Y..i5tockton.CA 95203 <br /> Generators Phone:62091322 0-3714 ATTNJrssr Lewis <br /> y U,S.EPA 0 Numuer <br /> 7 Trerrsppaor 2 Carrtparry Name US,EPA ID Number <br /> ted F and Address US.EPA 10 Number <br /> Clean Harbors Buttonvi illaw LLC <br /> 2500 WestLokem Road CAD 8 8 0 6 7 5 2 7 6 <br /> Buttomrillow.CA 93206 <br /> FUR s Phone. Mill 762-6700 <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,tD Number, 10.Containers 11.Total 12 Unit <br /> HM and Paddng Group(if any}) Na. Type Quantity W 01 13.Waste Caries <br /> }.NON-RCRA HAZARDOUS� WASTE,SOLIDS.(FLY ASH) 571 <br /> Z 2. <br /> L <br /> 7 <br /> 3- <br /> i <br /> 4. <br /> 1 <br /> 1 SeWg r]tgcttons avdAddillbrd Infomra w <br /> 1S. GENERATOR'SIOFFEROR'S CERTIFICATION; thereby declare that the contents of this consignment are fUiy and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledtplacarded,and are in alt respects in proper condition for transport according to applicable International and national governmental regulations.If export shipment and J am the Primary <br /> Exporter,I cerby that the contents of this consignment conform to the harms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if f am a large quantity generator)or(b)(I lam a small quantity.general is true. <br /> antame MWE Day <br /> ear <br /> 1 fnleara6orw <br /> Z ❑Import fc U.S. ❑Export from U,S, PIG alffvkal <br /> T for p Data. U.S.; <br /> 17.Transporter Ack mwledgment of Receipi of Materials <br /> tares 1 � `` Signature Day Ybm <br /> a UI rtfU1N <br /> ranepotlor 2 PrfntedlTypvd Name re ttt <br /> 16.discrepancy <br /> J, Day I vor <br /> 18a.Discrepancy Indication Space Quontity ❑Type ❑Residue U Partial Rejection ❑Full Rejection <br /> AitestRoforerlce Numhar <br /> 16bAlternateFacgity for Generaror) U S.EPA Ip Number <br /> J_ <br /> V <br /> F S Phone: <br /> Ll iBc.SigrahrM of Almmafo sadly(or Ganom x) <br /> a Month 013Y Year <br /> H19.Hazardous Waste Report Management Method Codes(I.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1, H132 2. 3: 4, <br /> 20,Designated Faeaty Owner or Operator:Cer0cation of receipt of hazardous matelots covered by the manifest except as noted in Item 18a <br /> NntedfTyped ams � Signature � tdori Ray Year <br /> IF For <br /> 0413 <br /> y, a ° 01e1s GNJ� F ILITY TO DESTINATION STATE 1F REOUIRED) <br /> ,. <br /> 0l rla' o penrkrts for and will accept the waste the gerte�aFi �Ii 511II plik ( <br /> d <br />