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-404 <br /> Please print or Form designed for use on elite(12-pitch) /� �V,?7 SC PPW '0/10J2017 <br /> p type.( g ( p )typewriter.) G'�a o l.�o / Farm Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone d.Manliest Tracking Number <br /> WASTE MANIFEST CAL 0 0 0 3 5 91 0 2 1 (800)4 3-3719 1 011583978 F L E <br /> 5.Generators Name and Mailing Address Generators Site Address(A different than mailing address) <br /> DTE Stockton LLC <br /> 2526 W.Washington Street 2526 W Washington Street <br /> Stockton.CA95203 <br /> Generators Phonef209'3=171-4 4 w d ,,�� r Stockton,CR 95203 <br /> .Transporter 1 Company Name U.S.EPA ID Number <br /> iiseS ,2001 f <br /> 7.Transporter ZCompany me U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Clean Harbors Buttonwillow,LLC <br /> 2500 West Lokern Road C A 0 a o 0 „o r :ser o <br /> FaBci s �nUow-CA 93206 <br /> 76-36200 <br /> 9a gb.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit ' <br /> HM and Packing Group(it any)) No. Type Ouantlty WI NoI13.Waste Codes <br /> a 1.NON-RCRA HAZARDOUS WASTE,SOLIDS,(FLY ASH) 571 <br /> ag a <br /> w <br /> Z 2. <br /> w <br /> C7 <br /> 3 <br /> 4. <br /> 14,Special Handling Instructions and Additional Informasan <br /> 1-117E641753E - <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and am classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of Ihis consgnment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I codity,that the waste minimization statement identNed in 40 CFR 21('d I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> enerato e s Printed yp Name igna ure on V a Year <br /> 'Z sor i9 <br /> 16.International Ship nts <br /> i 1:1Import to U.S. ElExport from U.S, of entryxif. <br /> Transporter signature for exports only): Date leavin U.S., <br /> K 17.Transport nowletlgment of Receipt of Materials <br /> w <br /> Transport 1 P' teal Ypetl Ne rgna L' Month Dai <br /> e <br /> QTransporter nnted/Typed Name <br /> K Month Day Year <br /> t— <br /> } 18.Discrepancy <br /> 182.Discrepancy Indication Space <br /> Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 186.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Q <br /> LL Facili s Phone: <br /> w 18c.Sgnzture of Altemate Fatality(or Generatw) Month Day Year <br /> Q <br /> z <br /> 19.y Hazardous Waste Report Management Method Codes(i.e,codes for hazardous waste treatment,disposal,and recyGing systems) <br /> 1. 2_ <br /> 1 <br /> Hi32 <br /> 20.Designated Fatality Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> PdntetlRyped Name -V'&C'�jj-4 Signature /1 Month DaL <br /> Vear <br /> C I \� <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> Clean Harbors has the appropriate Permits for and will accept the waste the generator is shipping. <br />