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XfC) 235-3 Sc <br /> 10/10/2017 <br /> W.print prtype.(Form tlesigned kr use on elAe(12yilch)typeenlec) ,� Form Approved.OMB No.2050-0039 <br /> UNIFORMHAZARDOUS 1.GenwWlDI4w1*r 2.Pagat of1 3.Emegarma'Rmpmu Pnam 4.11anwat Tmaltirg r <br /> WASTE MANIFEST CAL 0 0 0 3 5 910 2 1 (900)4933718 NumbeFLE <br /> S.Gamzlofs Nan@an M,AndAll G«re .Bile Ammam tlaisirmt Nanmailincammall <br /> 2526 W.Washirill Street 2526 W Washington Street <br /> Stockton.CA 95203 Stodpton,CA 95203 <br /> ,,wmwrs a,w,!2091320-3714 ATTNJesse Lewis <br /> .Tmmww I MR,M. U.S.EPA IDNmnbercorCoo J 991/ <br /> l En .f f)Se5 J 3 <br /> 7.TrempoNer2 Company Name U.S.EPAID umber <br /> B.Deagnaleb Fm llly Name aM Site Atltlmss US.EPAID Number <br /> Clean Harbors Buttornsillow LLC f.A v 9 9 O a 1 5 2 7 6 <br /> 2500 West Lokern Road <br /> Buttanwillow.CA 93206 <br /> Foal' Plwm. 16 611 762,6200 <br /> ga. gb.US.DOTDp W(iMumng Pnper Sbipging Name.H CI IDNwlber, 1O.Cgnwlnwn, 11.Pail 12.Urc1 <br /> HM arAPactlry Gnw(ifw,)) Nb ype TCaal MAm. 13.Wall Catlss <br /> 1 N0N-RCRA HAZARDOUS WASTE,SDLIDS,(f1Y ASH) 571 <br /> = 2 <br /> l br ygew p <br /> w <br /> 3. <br /> gguu4.aWNrgN <br /> 11_C96 375135nsaMAabiWalnWmaepn <br /> 15. GENERATOR'SWFFEROR'SCERTIFICATION: lhembyd mNal NemM MdMismnsgnmeMarehllyaMa[eurawlydesmbetlaWeby"pmpersbipoi name,aMaretlaes,pa gW, <br /> mal WWwpWcemetl.awl ate in all respects in propermMftn Whanapgrlmxxim g wappiail inwmatiaal and national gwemmenlal ra,,la u.IfexWshipmenland I am Ne Pmna7 <br /> EgwNer, truly Nat Nemm Pian s hlsmr¢ignmentmnQCR26 27(a p(I Iam aTMEPAAdm mama and (fl <br /> I mmlY Matra xate min'uniration sWhmanl itlenwM in d0 CFR 26227(a)(A I am a Wqe quentlty gerereloN ar @)(81 am a small quantity genere W)nine. <br /> ay <br /> A 'OTAe S43'1 e y I1 �O <br /> F <br /> 11; win a i,m 5M1ipm ❑InponwU S. ❑Exppn M1anUS. a US <br /> T <br /> � ranms retire We¢ onl Oeh kevl U.B.: <br /> W 17.Tmrepw,AJmwledgmenl d Rempl of MaWWh <br /> KTrawww l Plinletl?ypeJ Name Swill %onM Day Yaw <br /> O/) k 1 W 1.(1 <br /> TranspoRm2 PrintittlRygretl gnawre n Una, <br /> i18a.Usaeparwy lMim4cn Space ❑ owe, ❑Tyye ❑Resbm 1-1 All Pal 11 RA Relwban <br /> Mammal Rawmnce Numbe, <br /> 181Alhmeh Fadity(«Ge al U.S.EPA ID Numbm <br /> J <br /> U <br /> LL Fadl' sPMne' <br /> w 18c.Sierebae nfAmmw Pace,for Pane ) w4h Day Year <br /> a <br /> z <br /> N19.H8drdm¢WasW Rend Manmlemml MNhM Cgtlas(e.,mtleaWhaaNauewa¢h treabnent,tl yoaal.eM reryd'Irgayetema) <br /> 1. H132 2, 3. 4, <br /> 2).Da¢gnakN FaaliyTMmQx«Oper1ab�rJ:CeiAfimAonINreceipldhazadqusrreOleMh w+aMb)Cameriyeeleuept®mhd'n Ilam tBe (/ �7� <br /> ur <br /> 1 PmWN Pe Name Ve `SrriAm V V SOre EE��p�ppb� O I I D YGV <br /> EPA Fam Beall HlaNGo haStne]Dl pnateD imrts for and will accept thewastet genepjEjIOIkAJ%KILfiY TO DESTINATION STATE IIF REQUIRED) <br />