Laserfiche WebLink
el Fi-u �Z <br /> Generator acknowledges that no material change has occurred etther fn the characteristics or In the process generating the material. <br /> Please print or type. Foran Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL 0 0 0 3 5 91 0 2 1 (800)4833718 015225471 F L E <br /> 5.rm"o,atylsONatne an Mailiyg Address Generator's Site Address(if different than mailing address) <br /> 2526 W.Washington Street 2526 W Washington Street <br /> Stockton,CA 95203 Stoccton,CA 95203 <br /> Generators Phone:(2091320-3700 ATfN:GennVHuffman <br /> 6.Transported Company Name _ r.� U.$EPAID NQUy3y L�:� <br /> C C. (�"`\ 1 r'1 jL u um <br /> 7.Transporter 2 Company Name U.S.EPA Inumber <br /> B.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Clean Harbors Buttonwillow LLC CAD 9 8 0 8 7 5 2 7 6 <br /> 2500 West Lokern Road <br /> Buttonwillow,CA 93206 <br /> Facility's Phone'. <br /> 9, 91b.U.S.DOT Description(inducting Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Totel 12.Unit 13 Waste Codes <br /> HM and Packing Group(if any)) No. Type Ouanfity Wt.Nol. <br /> 0 1NON-RCRAHAZARDOUS WASTE,SOLI D.(ARSENIC,LEAD, <br /> VANADIUM <br /> LJ 2 <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> S.C1011.647999 <br /> Contract retained by generator confers agency <br /> 15. GENERATOR'S'OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper s ippmg name,a are class,Me !"N'3"A <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemationaland national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I partly,that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quantity generator)or(b)(itl am a small quantity generator)is true. <br /> GeneratoeslOte rs Pdntedrryped Ns a Signature Month Day Year <br /> .JOO s�12 �J .? 2d <br /> 16.Intemational Ship nts <br /> F ❑Impatlo U.S. ❑Export from U.S. Pod of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Tran rAcknowledgment of Receipt of Materials <br /> fransportl PnnLdffyplU Name Signature Mont, Day Year <br /> a <br /> (Cr1 d 3, zo <br /> z Transporter 2 Printedlryped Name Signature Month Day Year <br /> Q <br /> tY <br /> I <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space El <br /> Quantity Type Residue El Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone' <br /> lgc.Signature of Altemate Facility(or Generator) Monts Day Year <br /> Q <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2, 3. 4 <br /> Hi32 <br /> 20.Desg acinty 2!;9 or Operator:Ced lkmtb ipt of hazardous materials covered by the manifest except as ncted in Item 18a <br /> 1 P;r' 87y-)revious <br /> Na A gnature Month Day Year <br /> EPA editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br /> Clean Harbors has the appropriate permits for and will accept the waste the generator Is shipping. 7J 2003941220 PPW <br />