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Please t or ,(Form for use on elite(12:eft) iter.) SC PP W 10/10/2017 <br /> UNIFORM HAZARDOUS 1.09%ralor ID Number Form l3ruvad.OMB No.2050 39 <br /> 2.Page i Of 3.Emergency Respow phone 4 Alanifest Thackirhg Number <br /> WASTE MANIFEST CAL 0 0 0 3 5 91 0 2 s i$OOi 463-37ig FLE <br /> ONandC�IT Ort 9 I q Address Generators Siie Address(If dtffen3nt ptan maiiirrg address) <br /> 2526 W.Washington Street <br /> Soot*ton.CA 95203 2525 W Washir.gton street <br /> Generator's phone;(2091320-3714 ATTNJesse Lewis Stockton.CA 95203 <br /> I1.EPA ID Number <br /> 7. 2 yName <br /> U.S.EPA ID Nhanher <br /> a.Destgnaled Facility Name and Site Address <br /> Clean Harbors Buttonwillow LLC U.S.EPA Number <br /> 2500 West Lokem Road 4 A (3$ <br /> Bt tOnWilloW.CA 93206 <br /> I acili phone; (6611762-6200 <br /> ga. 9b.U.S.DOT Description"udN Proper Shipping Name,Hazard Gass,ID Number, l0.Containers <br /> HM and Pecking Group(H any)) 11.Total 12,Unit <br /> 1•NON-RCRA HAZARDOUS WASTE,SOLIDS.(FLY ASH) Type OuanBry WI-Nal. 13.Waste Ccdes <br /> 571 <br /> w z. <br /> ca <br /> 3. _ f <br /> 4 <br /> i <br /> '9 p�{�p�aglrucpons and Additions!Information ' <br /> 7--1rA6417,�..�YOO <br /> 15. GENERATOR'St FFEROR'S CERTIFICATION: I hereby declare that ate eonlents of this conslgrvnent are fully and accumlely described above by pre proper shipping name,and are classilled,packaged, <br /> marked and lebeledfptecarded,and are in all respects in proper cmdtiton for bans <br /> port PPAAAdmowto deble edgmant oetiorral and naliortai governmerhfal regulalione.If expod shipment and I am the PrimaryExporter,I cediy that rite cadents of this consignment eanlOne to the terms of the attached <br /> enL <br /> 1 cer*Ihat the waste minimizalfdn statement identified in 40 CFR 262.27(x)(if I am a large quantity generator)or{b](IIam a small <br /> Genera} quantity generator)is true. <br /> /Fjr �"i Oar <br /> F 16.tnlematiortat Shipm <br /> or ❑import to U.S. Exorl rom U.S.Ira s' port nhyl <br /> & 17.TransportarAcknovrrled Dale lea' U.S.: <br /> r gmattl of Receipt of Materixb <br /> rartspo&I Pd y� <br /> d1 S4 <br /> V) ear <br /> QZ Transporter 3 drdedfrypad Name <br /> w na onth Day Year <br /> 1e.Discrepancy <br /> 189,Discrepancy Indlcasm Space ❑ Oueniiy ❑Type <br /> ❑Residue ❑padiai Rejectlort ❑Full Rejection <br /> 18b.Ahemats Family(or Gem) 1liaferenoe t rwrdrer <br /> V <br /> U.S.EPA ID Number <br /> 4 <br /> a F s Flhone: <br /> W18c•Slpnahge.csfARem�m Faa wy or Gest) <br /> "In Year <br /> W19.Hazardous Waste Repot Management Method Codes(W.,codes for hazardous waste treatment•disposal,and tvrYOtln9 8ysterrta) <br /> t' If 132 2 3. 4- <br /> 20'DesrgnotedFadty Owner or OperaW,CeAikatlon of receiplof hazardous malerisls covered by the manifest except as noted in Item lea <br /> nted typed r,hwne <br /> Signature Month Day Year <br /> EPA Farm$7110.22(Rev. 3.03 tEtitNts a oh8alete, s� A� A <br /> Olean t T tit; a l e"'I S112e perinits for and WM a0cept the waste tltrr enel tnT��ftuG ILffY TO I?ESTWATIQN STATE(IF REQUIRED) +� <br />