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Please print or We. Foo dw9ned for use on elite I12-plkt f ZDD/7 `3 j $`C PP W 10/10/2011 Form i4pploved.OMB Na.2050-0039 <br /> UNIFORM HAZARDOUS 1•Ganeratar ID Number 2.Pape 1 of 3.Emergency Response Ptione A.Manifest Tracking Number <br /> YYASTE MANIFEST ICAL000359iO2 1 (800)4$3-3738 nil 51810M FLE <br /> ffWeAddrm Genera—Wo S0e (11 diftriant than mnlhrg address) <br /> 2526 W_Washington Street 1-526 W W ine�nn SL-eet <br /> Stodtton.CA95203 `��.. �5h "'^ •• "-�_ <br /> t3anerafot's Phone: <br /> (2091320-3714 ATTNJesse Leteris Stockton,CA 95203 <br /> U.S.EPA ID Number <br /> Kw%XWS_ C�,r e� <br /> 7.Transportvi2 Cerny Nance <br /> U.S.EPA ID Number <br /> f ty Noma and Site.Aft= U.S.EPA ID Number <br /> Clean Harbors Buttonwillow LLC <br /> 2500 West Lokern Road CAD 9 8 0 6 7 5 2 7 6 <br /> Buttonwillow.CA 93206 <br /> Ffdd s Phone: (6611762-6200 <br /> ga. i 9b.U.S.DDT Descriplion(arcludirig Proper Shipping Name,Hazard Class,ID Number, 10 Containers 11.TDt3I 12.Unit <br /> HM and Packing Group(8any)) No. Type Quantity WL%I, 13 Waste Codes <br /> F 1.NONACRA HAZARDOUS WASTE.SOLIDS,(FLY ASH) 571 <br /> Z 2. <br /> E <br /> 3. <br /> 4. <br /> 14 Sppees�ft HHaarn�ryp nsfructh=and i4dd+'6ortal ntormapon <br /> I.3=4ly 7 135 <br /> 15. OENERATOR'SiOFFFROR'S CERTIFICATION:I hereby declare Uiat the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper concilton for transport according to applicable tniemational and national governmental regulations.H export sNpnwt and I am Bre Primary <br /> Exporter,I certify that the contents of this consignment conform tD ire terms of the attached EPAAcknowfedgrnent of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(il I ren a large quantity generator)or fb)(if I am a small quantity generator)is true. <br /> n ay. year <br /> 16.Irdemational Shipmen <br /> ❑Import to U.S, ❑Export from U.S Portof lexi� <br /> Transporter signature for exRn onl : Date Ieavin U.S.: <br /> W IT Transporter Admowledgmant of Receipt of Materials <br /> S Ttanspdr 1. yP Yew <br /> 17 L2Q <br /> Z Transporter 2 PrintwIfTypo Nom MDM <br /> y Year <br /> 18.Discrepancy <br /> 18a.DL aWaxy lndlicabon Spam ❑ ouartlty ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest ReferenceNumber: <br /> 186.Alternate Facility(or Generaloo U.S EPA ID Number <br /> V <br /> Fang s Phone: <br /> LL, 18C.Sigrta4n.ClAtarcrale Facility.for Geirim ri. talent+ Ltay Year <br /> Q <br /> 19.Hezardous WasleReport Management Method Codes(i.e.,codes for hazardous waste lreatmen(disposal,and recycling systems) <br /> 1 H132 2. 3. 4, <br /> 20,DesignaW Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PnrNedl'f ergo �� �� uo [� ! kltin�n Day Y+rdr <br /> EPA Focm 87U(t-22(Rp. 3.0 � p yt 5 erg� �� f]F�SIGN DFA 1LITY TO DESTINATION STATE(IF REQUIRED) Id <br /> Clean hl alts as thtt aptpropnate pemtits for and will areept thew aste the genera err Is s pin <br />