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%ease print or type.Form designed form on alila(12-pitch) SCPPW 10/10/2017 Approved,OMS No.20SM39 <br /> g ( p ItYDerMNer3 Form <br /> UNIFORM HAZARDOUS 1.Gen -WONumber 2.Paget of 3Emmgemy RmpomePram a.MeasM Tracking Number <br /> WASTE MANIFEST CAL 0 0 0 3 5 91 0 2 1 18001493-3718 013584017 FLE <br /> 5. YS Names.failgp Adaress Gemrebh SBe PdtlmalBtlMerent Man mslMg amress <br /> n LCL <br /> 2526 W.Washington Street 2526 W Washington Street <br /> Gmckmn.G G6 XN 'l <br /> 03 9[otlrton,CA 95203 <br /> GararaMla Phone:�Nffl1 20-3714 ATTesse Lewis <br /> 6. remponermanr ame us FPA 10 Numlrer <br /> Sour War-A-Sam <br /> T.Tnerna r2 Lanmrry Nvre LL5.EPA IO it <br /> 8.Das'gmted Famliry Name and Site Mtlrass U.S.EPA IO Number <br /> Clean Harbors Butiorwsillow LLC <br /> 2500 Wen Lokem Road CA^-.960675276 <br /> Bldiorlwillaw.CA 93206 <br /> FaGliye Phord (9911 I'l <br /> ger WU.5.(0T0espipponiinam,Paper SNladn,Name,worm Cleea,IDNumbm, 10.Comanere 11.Total 12.Ung <br /> HM and Packirg Gmuplifanyl) No. Type Nam, dl 1J.Wate Cable <br /> rc t-NON-RCRA HAZARDOUS WASTE,SOLIDS,IFL7 ASH) 571 <br /> / all <br /> = 2 <br /> w <br /> 3. <br /> 14, <br /> 19.spetl A6Ha INr�136cYons antl PLdOonal lmomaeon <br /> 151. GENERATOR'SNFFEROR'SCERnRCATION: IM1erebytletlam mlMe mn@n6 of Mls arivgnment are M1tlly antl apzrelelytlesmbetl abore by Me pmper sM1iPoing name.antl are tlessified.pake,ed <br /> named am aba'aNplaarded,and are In all real m proper aatlRgl nr eanaporl acmrdin,to appliaMa mammal and nawdal govammmMl mguladmsf eeparr shipmentand I am Me Phmary <br /> E:morlx, cemry Mat Me anrenM olMq consimment anMm M Me firms of Me amm U EPAAIXnwdetlgmem olCmsmt. <br /> t army Mai Me wasre <br /> ans <br /> miN m matemam iaemsrea M ab ccR zsz.nlaf tel am a urge gmmip ganmatorl orlbf 1e l ams smell qurygemmlorl Is w <br /> New e <br /> Pnm rlrme yYear <br /> rJ S 61-0 <br /> 1, mmaemal SM1ipme s <br /> FL11nal. ❑ENladoornu5. Pmai eye <br /> i T nalure fine.ponapni Dwtear U.S: <br /> K 1I.Treralwder AG;mrledgrnentof Receiptol MatmMM <br /> CTrempmert PnnMNtyyetl Nameynature y re <br /> S gAar � ko 4 ZU <br /> TmWm r2 P m dT p d Nam gnawm ar <br /> i18.Namal <br /> 18a.I1hoepansy NNabon Sp® ❑ ate, ❑TYad ❑Readue ❑ParAaI R¢jectipi ❑FW FoJdtied <br /> MmAml Refe em,Number. <br /> 1w Almab Fatlfilylm GemMMff U.S.EPAO Nmmer <br /> V <br /> a <br /> a FarA Prag: <br /> Q tm5.�]mblR muremaM FatlMy laGarmralarl Mal NY area <br /> 2 <br /> H19.HaraNmaVnaM Relron Mxmpemml Matllgtl Cotles li e..mtlmbrMUNmuvaMe damrenl,tlRPmal,aM reryGing systems) <br /> 0 1. 2. 3. d. <br /> N132 <br /> M Desgnaletl Faa4 G.rndrofGmran.CmMaumadalofhademoa mMedasor added by Me 1 a mpraemled in Man lea FrnVetlRpad Name � Sail C� �l DY <br /> " Iv Z <br /> EPA Fo eai Rv.3-0 ) PreviausedibonSdreobsolete DESIGNA77EO FACILITY TO DESTINATION STATE QF REQUIRED) <br /> can HSr�oIs Ilas the appropnate pennies for and will accept the waste the generator is shtpptng. <br />