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SG PPW 101iO/2017 <br /> Please priN or .(Form d rreA for use on elite(12- itch) . niter,} 200T2. <br /> � r' Form .OMB Na 2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator tD Nrmtber Page 1 of 3,Emofgoncy Response f'hane MWIA st Tracking Vumber <br /> WASTE MANIFEST CAL 0 0 0 3 5 91 0 2 1 (800)483-3738II 5 O FLE <br /> one sato (i d fan rw _address) <br /> 2526 W.Washington Street 2626 W Washington street <br /> Stockton.CA 95203 Stadcton,CA 95203 <br /> omerawrsph.a:I`091 Ji0-3714 ATT141essp Lewis <br /> a. apo U,S:EPA ID Number <br /> T Trertsporlor 2 Company ame U.S.EPA ID Number <br /> B.0054hated Facillity Name DW Sito Address. U;S.EPA ID'NurntW <br /> Clean Harbors outtonvvillow LLC CAD 9 8 0 6 7 5 2 7 5 <br /> 2500 WestLOkern Road <br /> Buttonwillow.CA 93206 <br /> Facifd S Phone: Mill 762-6200 <br /> 9a. iib.U.S.DOT Description(Including Proper 5hgrping Name,Hazard Class,ID Number, 10.Gorhtainers <br /> 11.Total 12,Unit <br /> HM and Paddng Group(d any)) No. Type Quantity WLNbI. 13.Waste Codes <br /> ' NON-RCRA HAZARDOUS WASTE.SOLIDS,(FLY ASH) 571 <br /> 06 9?V <br /> Z 2, <br /> UJI <br /> 3. <br /> 4. <br /> 1 5�inn3pspardiurrs and Addkmnal atiors <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and amrrately desated above by the proper shipping name,and are dassified,pactraged, <br /> marked and lebeledfplacarded,and erein all fespecls in proper omMon for transport according to apprirable itlemabonai and narronal governmental regufefpts.If export shipment and I am the Primary <br /> Exporter,I cedly that the contents of this consignment ombTn to the terms of the ataMW EPAAdawtvledgment of Cement. <br /> I certify that the waste minimization statement identified In 40 CFR 282.27(a)(d I am a large graudky generator)or(b)(d I am a small quantity generator)is hue. <br /> woo UR <br /> Oar <br /> i 6 international Shipments11 <br /> Import to U.S. L_I Expw1 from U.S of en lest: <br /> — Tran oder si nabxe for ex orts only): Date leavi U.&: <br /> 17.TrarrsportatAciutowiedgmant of Receipt of Materials <br /> Nr Do Yew <br /> Trartspner 2 vnin . Signature <br /> 18.Disrxepancy <br /> 18e.Discrepancy Indication Space Quantity ❑Type ❑Res'due ❑Partial Rejection ❑Full FZ*Wort <br /> Manifest Reforewz Number: <br /> 18b.Afemate FarxTdy(orGuraretor) U.S.EPA ID Number <br /> t� <br /> w Fack' s Phone- <br /> LL' 18s sign UmorAnernateFaci*(orGgneralor) Month Day Year <br /> 4 <br /> Z <br /> 1 g.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling system) <br /> Lai C 1. Hi 32 2. 3. q <br /> 20.Designated Fadlily Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> IftiediTyped Name signature Month y ear <br /> tr a t. <br /> EPA Form le7 n H(R�vDarr, pfey�s ��y g�obsolete, 2�jfiVt j& FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> its s is ttk8 appreciate Permits for and will accept III. �,asle the.bene T4 Tlrt�_ <br /> z <br />