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Please print a (Form deaVW for use on elite 120tch)hTewriber.) SC PP W 10/10!2037 <br /> UNIFORM NAMDOUS 1.Ger'erator ID Number 2.Pae 1 of 3.ErneForm ,OMB No.20500039 <br /> 9 Emergency Response Phone �4.Majiftt Tracking Number <br /> WASTE MANIFEST CAL 0 0 0 3 5 9 1 0 2 i (900)483-3739 -LE <br /> 5. 9toN+�o�fft�Address Generators Site Address[t different than maum address) <br /> 2526 W.Washinpon Street <br /> Stoakmn.CA"&2&2 2526 W Washi"Aton Cw..* <br /> c <br /> erawrs Pnone:r209='23-3:34 ATTNJesse Lewis 3tadctan,CA 95203 <br /> yName <br /> U.S.EPA ID Number <br /> FTmPar <br /> S 2 Pany Name <br /> . esignated FdMY Name and Site Address <br /> Clears Harbors Bultt "VirillowLLC U.S.EPA ID Number <br /> 2500 West Lokern Road CAD 9 9 0 5 7 5 2 7 6 <br /> Buttonwillaw.CA 93206 <br /> Fadift's Phone: (6$31762-6200 <br /> ger, 9b.U.S.DOT De—p$on prwiuding ProperShippi g Name Flazsrd Class,ID Number, <br /> HM and Packing Group(A airy)) No Containers 11.TOW 12.Unit <br /> 11614 1No. Type QuenGty Wt1t/oL 13,Waste Godes <br /> c RA HAZARDOUS WASn.St?LIUS, FLY ASH) 571 <br /> 4b Q <br /> d. ¢ <br /> 1 � <br /> 14.-pastel WagVucuons and Additional Information <br /> i_C854l75b <br /> M GENE RATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of ft consignment are fully and accurately described above by tha proper shipping name,and are classified,paclteged, <br /> marked and lebetedOacarded,and are in all respects in proper condilion for transport according to applicable international and national governmental regulations,ff export shipment and I am the Primary <br /> Exporter,l car*that the cons of this consignment conform to the terms of the adarhed EPAAcknowledgment of Consent, <br /> I a+d4 that the waste minimization statement idertifred in 40 CFR 282.27(a)III I am a large quantity generates)or(b)(if I am a small quantity generator}is hue. <br /> F <br /> .�.w w. <br /> .Trans ❑Import W U.S. t_..I Export Born U.S. Pat entry __ <br /> (or ax Date U.S.: <br /> LU17.Transporter <br /> a 1 <br /> Yped <br /> r Y � <br /> 18.Discrepancy <br /> 18a.DlscrepancY Indication Space t--I Ouenlity El Type ❑Residue <br /> ❑Partial Refection ❑Fut Refection <br /> 18b.Altornate Fadwy :or Generator} Manifest Reference Number <br /> U S.EPA ID Number <br /> V <br /> LL <br /> Faciliwa Phone: s. <br /> f8c SignatureoFM19ol faFack(orCwta w <br /> x Month Day Year <br /> W19.Hazardous Waste Report Managentard Method Codes(i.e.,codes for hazardous waste treatment,dispj8nd recycling systems) <br /> t. H 132 12, 4. <br /> 20-Designaied Fadk Owner or Operator.Certification of receipt of hazardous materiels covered by the mxcept as noted in Item 18ag I 04f <br /> F0` or a wiwill accept the wthe geneFtjjgV%WWf 1ITY TO DESTINATION SAE(IF <br /> EQUIR n) <br />