Laserfiche WebLink
SC PPW 10/10/2017 <br /> Please WWor (Form denied for use on elite(12-pitch)t ter.) Form Approved,OMB No.2050-0038 <br /> UNIFORM HAZARDOUS 69M IU 5 9:10 2 12,fage 1 ofi 13� 4,Manes Tracking pure <br /> WASTE MANIFEST 5� FLE <br /> Guawa�r's She WhDrent than maling address <br /> 2526 W-Washington Street 2526 W Washington Street <br /> tnckwn,CA 95203 5iockton,CA 1'9520 3 <br /> GeftembesPhone; <br /> !2091320-3714 ATTN-Jesse Lewis <br /> 6. +.angriero!vary. U.S,EPA ID Number <br /> tc'Y- 4 GO &q C."c 00 <br /> .TmnapD tar 2 Cornpany Maims U-S.EPA ID Number <br /> 6.1J nand FarAlfy Name and She Address U.S.EPA ID Number <br /> Clean Harbors Buttonrrillow LLC CAD 9 8 0 9 7 5 2 7 6 <br /> 2500 Westtokem Road <br /> Buttonwdlow.CA 93206 <br /> Facility's Phone: (661)7 62-620 0 <br /> 9a, 9b.U.S.DOTDesc*on(including Roper Shipping Name,Hazard-Class,ID Number, 10.Contalners 11,Total 12.Unit <br /> HM r'9 No. Type Quantity WI.No1. 13,Waste Codes <br /> and Group[d sty)} <br /> 0 1-NON-RCRA HAZARDOUS WASTE,SOLIDS,(FLY ASH) 571 <br /> z <br /> W <br /> C9 <br /> E <br /> i <br /> 4. 3 <br /> 3 � <br /> 1 <br /> ' E <br /> 1i-S&OT"9h,"-s and Additional I ation <br /> 15. GENERATORWOFFEROWS CERTIFICATION,1 hereby declare that the contents of this consignment are My and acouralely described above by the proper shipping name,and are dassAw.pedaged, <br /> marked and lahaledlpbcairded,and are in all respects in piper coadNan for transport according to applicable international and national governmental moagons.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment cmdorm to the terms of the attached EPA Ack onledgment of Consent <br /> I cerlik that Na waste mnirrdzation stalernant identified in 40 CFR 2K 27(a)(if I am a large quantity generator)or(b)(d I am a small quantity generator)is true. <br /> ammm ' Y Year <br /> LIW <br /> 8.international W'"Is ❑Impart to U.S. Q Export tram U.S. Po entry! 't: <br /> Transporter signalutgr exports only): Date leavin U'S,: <br /> 17.TransporterAdmWedgment of Recelptof Materials <br /> Yrs . Day all <br /> w ngon, j,Transporter Pun Name s•e sfgnature ICZ1 monin Day Year <br /> �a <br /> r <br /> 18.Disaepancy <br /> 18a.Discrepancy indication Space ❑ o.lity ❑Type ElD Residue Pallial Rejection ❑Full Rejedion <br /> Hardiest Reference Number. <br /> I Sb.Almmato Facilly(or Generator) U.S.EPA ID Number <br /> to <br /> U. Fedlf s Phone: <br /> W 18c. ignatore of Allemate Fac ity(or Genarator) Month Day Year <br /> F� <br /> N19.Hazardous Vbde Report Management Method Codes(i.e.,codas for hmmrdous waste Irealment,disposal,and reey ng systems) <br /> 0 1" H132 2. 3. 4. <br /> 20.Designated Facdlty Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted N Item 18a <br /> ftmirrym��uS ae>��Name Signature r04 08 Day Y. <br /> EPA Fare l �• Rstc 34.5}aS a0 i9inr�s a Dorm"for and wi11 accept the waste the� �����ILITY TO DESTINATION STATE(IF REQUIRED) <br />