Laserfiche WebLink
Please print or . Fonn dedowd for use on elite.12-pia) pevrritef.) Z(}0- , Sc PPw LoAo,r200 <br /> Form ApKOW,OMB No.2050-01]39 <br /> UNIFORM HAZARDOUS 1•Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.WMIllost TMdft NunAw <br /> F L E <br /> WASTE MANIFEST GAL 0 0 0 3 5 91 0 2 1 19001493.3718 <br /> 5. s n -amara a s{ dt6eranl Man melting address) <br /> 2526 W.Washington Street 2526 W!+:ashi9con Street <br /> Stodtton.CA 95203 Stodrton.CA 95203 <br /> Generators Phone:(2091320-3714 ATTNJesse Lewis <br /> nn U.S.EPA ID Number <br /> EPAID Number <br /> 8,Deslgnaiodaciifty Name and Site Address U.S.EPA ID Nurturer <br /> Glean Harbors Buttonwillow LLC CAD 9 8 0 6 7 5 2 7 6 <br /> 2500 West Lokem Road <br /> Buttonwillow.CA 93206 <br /> Fac' s Phone: (661)762-6200 <br /> ga. 9b.U.S.DOT Description(induding Proper Shipping Name,Hazard CIas,ID Number, 10.Co ntaiters 11.Total 1 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity WtMI. 13.Waste Codes <br /> f"NON-RCRA HAZARDOUS WASTE,SOLIDS.(FLS!ASH) 571 <br /> � <br /> 2, <br /> 3. <br /> 4, <br /> 3 <br /> 14.Special Handling Inshuctions and Additional Information <br /> 1_IrH64175315 <br /> 15. GENERATOIrSlOFFEROWS CERTIFICATION: I henry declare that me cordents of this conW9 tmeal are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked arhd labeledlplararded,and ere in all respects in proper condition for transport aowrding to appicable international and naknal gwemmenlal regulations.If export shipment and!I am the Primary <br /> Exporter,I codify#9 the contents of this consignment conform to the terms of the attached EPAAcinovAedgmentof Crnhsant. <br /> I certify mal ma waste minimization stabament identified in 40 GFR 262,27(a)(if I am a large quantity generator)or(b)(if t am a small quantity generator)4 true. <br /> Genund ns. <br /> 7 <br /> J 16,International 5hipm la ❑Import to U.S. ❑Export from U.S. <br /> T ors'nature for ex its Dale leav' U.S.: <br /> w i7.TransporlerAckrawledgmernt 22sw of Materials <br /> vana�z;r <br /> ear <br /> 6 <br /> mnspwW2 WTyped Name Uignak" M" Day Year <br /> r <br /> 18.Discrepancy <br /> 18a.Disoropency Indication Space Ouanttiy ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> a Facili s Phone: <br /> 4W I k Signature of Alternate Wy(or Geaeralorf Month Day Year <br /> x <br /> N19.Hazardous Waste Report Management Me"Codsa(i.a.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> t. Hi32 T4. <br /> 24.Designated Facility Owner or Operator.cerulicatlon of receipt of hazardous materials.covered by the manifest except as noted in Item 117a <br /> Printedlfyped Noma igna[ume f�n Day <br /> Ei4" -- I <br /> -a 110 <br /> EPA Form 87M22(Rev.Z-05) Previous editions are obsolete, DSIGHAF AVILITY TO DESTINATION STATE(IF REQUIRED) <br /> clean Hat!bOrs has the APPIOuriate permits for and will aotept the waste the ener or is s �r� <br />