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Please print or Form .Ior use on elite i2 patchy. i -� PP W 10/10/2017 <br /> 1.Generates ID Nrunber Form ved.OMB No.2050x39 <br /> UNIFORM HAZARDOUS 2.Page 1 or 3.Emergency Response Phone 4.Nwirest Tracking Nwobw <br /> WASTE MANIFEST c A L 0 O 0 3 5 91 0 2 1 (8001483-3718 15840 FLE <br /> 5. g Address erato s Site Address I' different than mating address) <br /> 2526 W.Wa�sphiirt�_(Mm Street ?a W rrt��k:„a, „�+f.e <br /> StOdUon.CA 952'03 r�� x1.�.ert. 3n Street. <br /> Generators Phone:(2091320-3714 ATTNJesse Levvis stockton.CA 95203 <br /> c.TransporterIarrye <br /> t/ , � S � U.S.EPA ID Number <br /> t` ,� -ire✓ t5'�5 q � <br /> 7.Transporler-21company Name U.S.EPA ID Number <br /> B. ;Zted Facc7cly erne andSde Address <br /> Clean Harbors Buttonwillow LLC U.S.EPA 10 Number <br /> 2500 West Lokem Road C A 13 9 9 0 g 7 5 2 7 6 <br /> BtmonrrilloW.CA 93206 <br /> Feat s Phone: — (66Z 792-6200 <br /> ga. 9b-U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Centel nere 41.Total 12.Unit <br /> HM and Pang Group(r any)) 13,Waste Codes <br /> No. Type Quantity WtW. <br /> 'NO RCRA HAZARDOUS WASTE.SOLIDS,(FLY ASH) 571 <br /> w 2. <br /> 3 <br /> SSSS---------- <br /> 4. �._._ __.....-_.._ <br /> i <br /> 19.SOMIINIAcltans and Additional krfermabon <br /> 15. GENERATOR'SIOFFEROR'$CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by dee proper shipping name.and are dasafied,paclwged, <br /> marked and lab atedraacarded,arid are in all respects in proper oondifion for transport according to applicable International and national governmental regulations.If export shipmerd and I am the Prknery <br /> Exporter,I certify that the contents of this conslgnmenl oodorm to the terms of the attached EPAAdrnowledgment Of Consent. <br /> I cadthat the waste minimitation statement identified in 40 CFR 28227(a)('d I am a targe quantity generator)or(b)(91 am a small quantitrtrdedrFyW Namy g;narator)is true. <br /> -�^ Usy ftir <br /> 16.Intern n S I m <br /> ❑Import to U.S. ❑Export bomU.S. Po en xil,._..-.-W.___.-.._______w ..___-.. <br /> Tran elute far ex dh <br /> Dale leaving U.S.: <br /> 17.Transporter AdmwledgneM of ReoW of Materials <br /> Vier Y ©� yLu <br /> ! S <br /> TransErader 2P, ypw mma �' ar <br /> mwfflaw Y year <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space 4uentily ❑TYPe ❑Residue <br /> ❑Partial Rejedlon EI Full RejecBon <br /> 18b.Alternate faaTManifest Refamme Number:ly(pr Generator) U.S.FPA ID Number <br /> C1 <br /> LL <br /> FadkVlq PMne: <br /> W lac.SignaWre of A inmate Facility(or Generator) Montt Day Year <br /> C <br /> Z <br /> c9.19,Hazardous Waste Report Management Method Cartes(.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1, H132 2. 3. 4, <br /> 20.Designated Fatty Owner or Operator:Cerdfitation of receipt of hazardous materials covered by the manifest except as noted in Item 1Be <br /> ft"Ty—ped Nam <br /> a <br /> �, Stgrataro f„�,, <br /> rS 3 1 D o `LO <br /> EPA FB700-22Msp0e (trtle�lt6 for and will accept the waste ttrflt�llILITY TO DESTINATION STATE(IF REQUIRED) F <br />