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Please print Dr type.(form deserted for use on elite(12-0141h) .) -ZQU 3" SIC PPW 10/10/2017 Farm Approved.OMB No.20SH039 <br /> UWFORfM HAZARDOtil <br /> 1.Generator ID Number 2.Page t of 3.15morgency Response Phone Manifest Trm* Niurdrar <br /> WASTE MANIFEST AL 0 0 0 3 s 91 0 2 1 (800)483-3718 011984002FLS <br /> Oareg to f fan ma€Ang <br /> 2526 W.Washington Street 2526 W Washinaon Street <br /> Stt:ooktae_CA 96203 9tockton,CA 95203 <br /> GeneratesPhone:(2051320-371 ATTNaessleI.e Vis <br /> 71mrpolldf I Man* U.S:EPA-D Number <br /> T ! A 000 <br /> .Qr7 Transporter 2 Nanee U.S:EPA ID Number <br /> 8. Folity Name and ft Addrm U.S.EPA ID Ntnnbor <br /> Clean Harbors ButtonwilloW LLC 4:, R S v^ 6 i 5 2 i 6 <br /> 2500 West Lokem Road <br /> ButtonwigOrr.GA 93206 <br /> FaA es Phone: (6611 7 <br /> 98, 9b,U.S.DOT Description iincluding Proper Shpping Name,Hazard Class,113 Number, 10.Conte€oars 11.Total 12.Unit <br /> HM arid Pecking Group(if any)} 13.Waste Codes <br /> No- Type Quantity W1.Nol. <br /> "NON-RCRA HAZARDOUS WASTE,SOLIDS,(FLY ASH) 571 j <br /> Z 2 <br /> t9 <br /> 3. <br /> 4, <br /> I <br /> 1 I <br /> 1 <br /> 19. fJwhoos mrd Additional lnkmrasore <br /> 15. GENERATOWSIOFFEROR'S CERTIFICATION; I hereby declare that the contents of this consignment are firtiy and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labefeWipecarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter.I cert€1y that the contents of this consignme:rn conform to the terms of the atladred EPAAdmowledgment of Consent <br /> I certify that the waste minin*Ation statement fdenfified In 40 CFR 262.27(a)(f I am a large quantily generator)or(b)(81 am a small quantity generator)is true. <br /> Printed/Typed Irma B monin Day Yea <br /> :: <br /> - -j <br /> J 18 Inti ElExport from U.S. Port <br /> F Import to U.S. <br /> � T rtar ow: t?atE <br /> a 17.TransporierAcknowledgnmt of Receipt of Materials <br /> Tmnspottar I F~Typed able Iur9 ear <br /> Trdrrspwter 2 yped ay yew <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication space ❑ Quardy ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b,Alte ntale Facility(or Gomm U.S.EPA ID Number <br /> {a <br /> � F sl�tiona: <br /> 18c.Signature of Wlttnnate Faialy(or Generator] Wrath Oey Year <br /> Z <br /> Z <br /> 0ro <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment.disposal,and recycling systems) <br /> a 1. Hi32 2. a. 4. <br /> 20,Dasigrtelod Facility Owner or Operator.Co fication of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Prirda ypeuf Marne. Signawre Mcdh Day Year <br /> v S 467' o of Z> <br /> to <br /> EPA Form 6700.22(Rev. 3-05) Previous editions are obsolete, DJSIGNATED I•APILRY TO DESTINATION STATE(iF REQUIRED) <br /> clean Harbors has the appropriate perntrts for and will accept till waste the�ener or is s ppin . <br />