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Please pont or tE2,(Form designed for use on eliia(12-pilch)typewriter.) Z DDI g SC PPW 10/10/2017 Form Approved.OMB No,205Q-0g39 <br /> UNIFORM HAZARDOUS t Generator ID Ntywws 2 Page 1 of 3.Emergency Response Phone 4. Tracking umber <br /> WASTE MANIFEST C A L 0 0 0 3 5 91 0 2 1 (800)453-3718 0117 91061 FLE <br /> 5ftmuw Adakess C*TX"ters Site Ad-d-mas-(Yd&mnt thea malirg address) <br /> 2526 W.Washington Street w WMchinewnn a+.4rt <br /> Stodnon.CA 95203 8todcron,CA 95203 <br /> GeneratoATSHJesseLevris <br /> mrtPmrtnr U.S.tPA ID Number <br /> l <br /> pG 3 1/3 <br /> 7.Tri?wwripany Name U.S.EPA ID ltihrmber <br /> 0 tedfaaxTily Name and SMAddress U.S.EPA Id Number <br /> Clean Harbors Buttonwillow LLC <br /> 2500 West Lokern Road C A D 9 8 0 6 7 5 2 7 6 <br /> Buttonwillow.CA 93206 <br /> Faa N.Phone: {66ii 762-6200 <br /> ga, gb.U.S.DOT Desaiplicn(IncWd%Proper Shipping Name,Heard Closs,10 Number, 10.Containers 11,Total 12.Unit <br /> HM and Packing Group Of any)) No. Type 4uamity WUVOI, F5711 <br /> es <br /> c 1'UN1759,COR ROSIYESOLI DS.N.O.S.,{ARSERIC,CHROMIUM� yl/,sy <br /> x 9,PG I II,(BOTTOM ASH? !_. .. .... <br /> W <br /> Z 2. <br /> W <br /> C9 <br /> 3. ------- <br /> 4- <br /> 14,Special Hng+tt6%Ins andAddlaataf 1nfomn4*n ) <br /> 1-CH1346380 IMG#154 <br /> 15, GENERATOR'SIOFFERBR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are cteasitied,packaged, <br /> marked and labeledlplacarded,and are in all respects to proper condition for transpurt according to applicable international and national governmental regulations.If export shipment and i am the Pdmaay <br /> Exporter,I certify that IN contents of this consignment conform to the terms of the attached EPAAcknowledgmeni of Consent. <br /> I oardfy that the waste n1i imltetion statement identified in 40 CFR 262.27(a)(if I am a large quantity genoralor)or(b)Of I am a small quantity generator)Is true. <br /> Gainamtoewonsprs Frin yptxl uro y ear <br /> 6 <br /> J 18.infellr8llartgl <br /> f'- ❑import to U.S. ❑Export from U.S. of o wexit: <br /> Tuns 5 . tura 00roz Date VS.-, <br /> CM17.Transporter AdmWedgment of Receipt of Materials <br /> rT.Transpoter 1 n ams eco <br /> 0 spr,tar2 Printedli7ypedName lure Lional 06? ear <br /> 18.Oiscreperlcy <br /> 1 Be,Discrepancy Indication Space F] Quantity ❑Type ❑Residue ❑Partial Rejedim ❑FLA Rejection <br /> Marwest Refor[tnre Number. <br /> 1166.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL W '9 = <br /> Aminate Facility(or Genetalar) mons 0& Year <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C 1. . I2. 3 4. <br /> Hi32 <br /> I20,Designated Fack Owner or Operator.Certification of recatpt of hazardous WD-WIs covered by the manifest except as rioted inItem 18a <br /> PrWX&TY*'NK" C" mum Day Year <br /> Q- " ) q 6 Izo <br /> EPA Farm 8700.22(Rev.3-05) Previous editions are obsolete. DEBWIIHATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> Clean Harbors has the appropriate permits for arid will accept the waste The generate;is Ipping. <br />