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Please Print or Ind.(Form designed form on nide(12-pdh)typeMdtarJ / SC PPW 7/12/2019 Form <br /> Approved.OMB No.2D50-0039 <br /> UNIFORM HAZARDOUS t.Ganem"DNumde 2bateld 3 Ebert Rasporam FM1ne 4.Man Nen Traokl Number <br /> WASTE MANIFEST CAL 0 0 0 3 5 91 0 2 1 (800)49S-371.9 0119(4 3 2 4 FLE <br /> off, NameaM W IVAWdroue Gsiveni Ske Ammons(it EMemnt Oren ani Moment <br /> LL <br /> 2529W Washington Street 21 W W arhim lba.Btroet <br /> Stockton.C�A9 %2 3700 ATTNGenrW HuHmWk Stocktani 95203 <br /> Gonot phone <br /> 6. partitioned Comi US.EPA 10 Nuader <br /> N <br /> L Trenspadn2 rry Name US.EPAID Number <br /> B.Desgnatetl Fa lMNameaM SHelWtlress V.S.EPA ID Number <br /> Clean Harbors BrntorlWrillow LLC <br /> 2500 West Lpkern Road <br /> Buttomvillow.CA 93206 <br /> FeriPMna: 1762.6200 <br /> qa, <br /> at.U.S,DOT oesmpim(ibaedlrg Proper Shipprg Name.HaaN ash,ID Number, 10.Corta'rmrs It Total 12.Unk <br /> IgA, andPaGbg Gmupprenyll No. T1Pe Gu my vi <br /> did <br /> Calls <br /> rc1UN1759,CORROSIYESOLI13S•N.0S.,0IRSENIC,CHROMIUML 571 <br /> X S.Pc Ill.(BOTTOMASH) <br /> w <br /> IL <br /> 3, <br /> 14 <br /> 1 311ritllt��ppns all MdilmYlafIbn <br /> coni retained Da aenefdtor conifers acenCY authorhY On Initial trdn500lter to add Or SUDistRllle addlpOR21 trapaDoin i ON Oenendars bchah <br /> 15. GENERATOR'SIOFFEROR'SCERnFICATION: IM1ereby tleaare MNNe conNMa of Nis mnN9mm�tare lellyantlamsmtNy OesMM1M aboveMNe PopersMpprg nalne,aM aretlanfietl.patlaged. <br /> mi and labelMlpWakad,all am In all mspeas'm prt oer raMigmlor transpod swsd g b applicable"Mordigbrel and rehonal gbemmenW releMtbm.IfegpM1SM1ipment and 1 am Ne ft., <br /> Exporter,I ceraly Nat be omfanN ofthis ronsgnmebt Wbbrm Oft terms of Ne meted EPAA nowletlgment of Gnsmt. <br /> IreMythaltMmskminm¢ nsUementiden in4OCFR2a227(a)(HlamalaWgy nblygenerata)or(h)(Blamasm 11,U.6rygene2taoisbue. <br /> Demandmr eml mi YRTR.—me— Mori Dir, Y. <br /> 1LA 110120 <br /> 1fi.Intematiowl SM1ipme ❑Ope0b LL5. ❑EspMM1om LLS. P ell <br /> Tau er si nature tree onl Date bavin U.S.: <br /> do 17.TlamanterAoftMedgmnaffodead fMaNreb <br /> ETransponder t PnnrMrTyped N. severe Mmor Da, Y. <br /> Vii /Y LA 16 2 <br /> ?�. Tramporler2PfeeWryIpMName 'i sY ear <br /> F <br /> ♦I 18.Dmepa y <br /> I 18e'GurparrylM hon Spu° ❑ Qui ❑Type 1:1 Residue ❑PaNal Repction El Full Redmn <br /> Mani@sl Reference Numbo,. <br /> 181.AMOMMFeafMla Generates) US.EPAIDNembn <br /> U <br /> 6 <br /> u Foal 's Phone: <br /> 181 Sgnalure of Alternate Faddy(or GererMor) Monty pay Year <br /> 2 <br /> y19.Haeadoes Wasde Rei Mne9ement Madam Codas(I.e.,mtles Or madarsweae heaMeme,domsal.AM morolde sy9ema) <br /> do 1. <br /> H132 <br /> 20.contorted FailM Ormanm Opnafor.Coldoo onofremor WFazand.netnieR cwarse by Ma mamfen aemq as mated in Ibm IN <br /> 1 POnladRypetl Naft I searta Monts oay Yeer <br /> EPA Form 8700.22(ReY.3-05) Previous edriorsaam Obsdeta. ILITY TO DESTINATION STATE IF REQUIRED <br /> clean Harbors hasthe appropnale perces for and will accept the wa a the r<ene�$�iW�d ( I <br />