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SC PPW 101i0t2017 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) 200178'1/357 Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS ' la"ypi 5 9 10 2 2�age 1 of 3� C �tlone 4.Manliest Tracking Number <br /> WASTE MANIFEST V V 1L! 01 5 8 4 0 LE <br /> 5.Q1LqMRNIfiV eftQAddress Generators Site Address(4 different than mailing address) <br /> 2526 W.wad&kaon Street 2526 w washiniew Street <br /> arr,&.r,.. ra 957AQ Stodtton.CA 95203 <br /> Generators Phone:(2091320-3714 AM Jesse Lewis <br /> 6. ransporter mpanyka.-6,W-r <br /> U.S. PA ID Number <br /> Q <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8,Designated Facility Name and Site Address U.S.EPA ID Number <br /> Clean Harbors Btt awmillow LLC CAD 9 8 0 6 7 5< 1 o <br /> 2500 west Lokem Road <br /> Buttonwiilow.CA 93206 <br /> Facility's Phone: (6611762-6200 <br /> 90 9b,U.S.DOT Description(inducing Proper Shipping Name,Hazard Class,ID Number, 10.Containers11.Total 12,Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wl.Nol. <br /> o I'NON-RCRA HAZARDOUS WASTE.SKIDS,(FLY ASH) 571 <br /> / DT o � <br /> = 2. <br /> W <br /> C9 i <br /> 3. I <br /> 4. <br /> IS <br /> .t*9Vr1%5rns.and Additional Information <br /> 15. GENERATOR'SK FFEROR'S CERTIFICATION: 1 hereby declare ehal the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledfplacarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.H export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the lemis of the attached EPA Acknowledgment of Corsent. <br /> I certify that the waste minimization statement identified In 40 CFR 26227(x)(d I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> eraw s 'ntedrT na re ear <br /> A <br /> 16.International 5' is <br /> ❑Import to U.S. EIEvort horn U.S. Port entryl <br /> Transporter signature for exports only): Date leaving U.S.: <br /> I= 17.Transporter Acknowledgment.of Receipt of Materials <br /> Transporter 1 Printe&Typed Name ne re y Year <br /> O I rr �ft l -x�} <br /> a44 czt:Ilk <br /> z Transporter 2 Printedfryped ame Uay Year <br /> 18.Discrepancy I�t <br /> 188.Di;srrepanA'rd-icationepace,* _nT,,,p _ ✓� <br /> • ` & M�/AAA tl El`e`j�a��''-L• Manifest Reference Number: <br /> 18b.Alternate facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> U <br /> a <br /> r+- FeCil' s Phone: <br /> W 18c.Signature of Allemate Facility(or Generator) Month Day Year <br /> H19.Hazardous Waste Report Management Method Codas(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> C 1 �f ar3 <br /> j -z- <br /> 20,Designated Facility Owner or Operator.Certification of reeeol of hazardous materials covered by the manifest except as noted in Item 18a ON Aj <br /> Printed/Typed Name / Signature Month <br /> jiGr'1.� jgi� 041 nil. <br /> EPA F ,_ 6 Will ae0ept the wale 4e� ILITY Tq DESTINATION STATE(It=REQUIRED) <br />