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Please rinl or h� .(Form designed for use on elite 12-Mch)l er. SC PPW 14!10/2017 <br /> Q � 1 �4�1I � / � Form Approved.OMB No.2Dso-oD3s <br /> UNIFORM HAZARDOUS 1-Generator ID Number 2.Page I of 3.Emergency Response Phone d.Mart e1 Trac u <br /> WASTE MANIFEST CAL 0 0 0 3 5 9 i 0 2 1 (800)483-a718 011 X91062 FLE <br /> 5• ifffWMIZGarwelor's Silo Address II ftn maft address! <br /> 2526 W.WashinMW Street 2526 W Washington Street <br /> &toaktan.CA 95203 Smt*ton,CA 96203 <br /> MAO%9P1A 7741 A ATnu.�.......,1.—A- <br /> GenefatoftPh",4A6v.ir.r�v-.rri-r naI11.0022aa.crran <br /> 6.Transporter I COMONy NA U,S.FPA 110 Number <br /> 7.Transporter 2 CompdrV Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> C <br /> ean Harbors BuIltonwillow LLC ;AD S 8 4 6 T 5 2 T S <br /> 2500 West Lokern Road <br /> Btmnmrillow.CA 93206 <br /> Fadlif s Phone: (GOD 7SM200 <br /> ga• 9b.U.S.DOT Description(inducting Roper Shipping Name,Hazard Class,ID Number, 10.Containers 11,Total 12.Unit <br /> HM and Padang Group IN any)I13.waste Codes <br /> No. Typo Quantity Wuleol. <br /> 1 UN059,CORROSIVE SOLIDS' <br /> N-O.S-,(ARSENIC,CHROMIUK 571 <br /> x 8.PG Ill.(BOTTOM ASH) <br /> Z 2. <br /> LU <br /> 3. <br /> 4. <br /> 1Q Sr ljESJ1 ryCfipnsan, <br /> vmmli rt <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedam that tlhe contents of this consignmentare fully and accurately described above by the pmparshipping name,and are classified,packaged, <br /> marked and labeledlptacarded,and are In at respects In proper condition for hanaport according to applicable Intematonal and national governmental regulations.H export shipment and I am the Primary <br /> Exporter,l certify,that the contents of this consignment conform to the terms of the stlecbed EPAAckraMedgment of Consent. <br /> I certify that the waste mininiration statanent identNed in 40 CFR 282.27(a)Iif t am a large quantity generator)or(b)(t 1 am a shed!quantity generator)is hue. <br /> s 'W' .06 =44W Z"o <br /> ar <br /> Nd <br /> � 18.mtemetlonat Shiprr�rhtS ❑ �Import to U.S. Q Export Iran U.S. Port try nb <br /> Transporter signature far exp2q onl : Date leavi U.S.: -^ <br /> W 17.TransporterAcknowledgmenl of Receipt of Malaials <br /> 12 Trans yped oma eat <br /> a. sy 7 Zd <br /> a <br /> Transporter 2 priniedl ypedi None MWO EW YW <br /> 18.Discrepancy <br /> 18s.Discrepancy Indication Spare Q Quantity ❑Type ❑Residue ❑Partial Rejection L1 Full Rejection <br /> Mandosl Rare ante Numbec <br /> 18b.Alternate FwW(Gr Granafatwl. U.S.EPA ID Number <br /> v <br /> LL EaLtll S PMxie: <br /> W 18c Signature 41 Mwriato Facwty for Geo&atorl Monih Day Year <br /> 4 <br /> Z <br /> HIS.Hazardous waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and revy&.g systems) <br /> p 1. 2 3, 4. <br /> H i321 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pnntedlryped Name Signature Month Day Year <br /> 0;.s as 1L.-f,top, I I og jel <br /> EPA Form 8700-22(Rev. 3.05) Previous editions are obsolete 010 DESIGNATED FACILITY To DESTINATION STATE(IF REQUIRED) 0. <br /> Clean Harbors has The appropriate permits for and will accept the waste the henerator is shippin;t!_ <br />