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�56Z>� <br /> Please print or type.Food designed for use on elite(12-pitch) 2,00 3s SCPPW 10/10/2017 Form Approved.OMB No.205W39 <br /> UNIFORM HAZARDOUS 1.Dermmlm lD Number 2.Pageld 3.Emmprcy Pssponse PM1oro 1.Manihsl Trac king NumMr <br /> WASTE MANIFEST CAL 0 0 03 59102 1 (800)4833718 FLE <br /> 5.Cem®Iys Napaan Mv PAdeas GeneretNs SAeAtltlreu'anomnlNanmaia aWreSsl <br /> 22526 W.Washington Street 2526 W Washington Street <br /> Stooktnn.CA 95203 StookitD A 95203 <br /> Somarmrsamne:f20913203714 ATTNJesse Lewis <br /> mmponer I Comins,Nor US.EPA ID Normal <br /> T.Tmnmamr2 yName US.EPAID u <br /> 8.Desgunac Fadliry Nameand 4e Adbmes US.EPAIDNumber <br /> rClean Harbors Buuorweillow LLC CAD 9 8 0 4i 7 6 2 7 8 <br /> 2500 Wen LoIcem Road <br /> But omsillow.CA 93206 <br /> Frismads.Pana: !6611762£200 <br /> ga, 9b US.DOTOesrhD (mdWkGProper SkppMNaas,Hamd Cksa,IDNum ,, 10Cpnakaaa 11,1011 12,Unit 13.1Vaste Cotler <br /> HM antl Padung GmuF(XanYll No. Type Oil mNd. <br /> rc 'NON-RCRA HAZARDOUS WASTE,SOLIDS.(FLY ASH) 571 <br /> 0 <br /> d.2, <br /> w <br /> 3. <br /> 4. <br /> 14.Spedal InsbudunS antl AtltlNonal InlprNtlon <br /> 1.[III541741T53D <br /> 15. GENERdITOWSPOFFERN'SCERfli'll herebytlsdammattoo 4anal oansignmenlme fully and afGemklyflada 0stma by C20mparshippng name,and ale mainland pecial 1, <br /> markW and IabekNDlacaded antl are in all respea6 in pmwrwWNon Mban¢Irmlaarodly to applicable Inlemairnal aW naliorelgovemmenml mgulalions.Xeapol rMpmanland I em tln Prarary <br /> EaPO mal anal <br /> minima dmk ensgnmam wn(0CFIme4mla dmeata si EPAAcknmamaks)or(b Lif Iaml. <br /> t mtiry mat ma wrak minim®Xm sskmem oenlirretl o 4p cf x zezzr(rl(dim a drlge auadiry�remNO or(bl(u l am a small guanliry genemt0n Is we. <br /> s ylNtldo blond Da, from <br /> A 871 4 )o <br /> in Indarmaral drilmainsis <br /> ImpMmU.S. ❑Ekppdham U.S. POtO nl <br /> et <br /> Tnina ,US <br /> raNm for dsw Date leamn US.: <br /> 1T.TmoswllarAckgMetlgmd4d RawlDt d Makrals <br /> 333"' Na <br /> m 1 - ylxO me 1 Y. <br /> / Y <br /> T (CyTmnspnkr2 y <br /> ♦I ti.D¢vepermy <br /> I iia.Dsm,noy Indication Spew ❑ DuNroty ❑Type 1:1 Road. Ll armed FajacMon ❑FWI Rejection <br /> Mal Formosa Number. <br /> 18b Atemak Finsily(Or Gerandi US,EPA ID Number <br /> U <br /> Q <br /> LL <br /> Fool Foods, <br /> 18c.51grMeee dAllansle FatlMy(a GeramWrl Moret Day Ywr <br /> z <br /> y19.Hemdprs VAeda Report Mnugaienl Metlwtl Catler(is..cages fa M1ezadous wWe0ae0rrent dismal.add recycFng syrlmrs) <br /> 0 t. z. a 4. <br /> H132 <br /> A Dasgwlstl FadXYoar uOPo2br:GNFr&nndr ptdM1an meknMsmvc byftmel excWn ce mit IM <br /> 1 Pmmkry so N. •� Namara Mmm Day Year <br /> I—Es JS 'i I 40e�� 104 1 10 17.0 <br /> EPA Fan 8700.22(Rev 3IDS) Prewar editors are absdele. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> clean Harbors has the appropriate permits for and will accept the waste the generator is shipping. <br />