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Please print or type.(Form designed for use on elite(12-pitch)typewriter.)419/5 4F-7 SC PPW 10/0/20V 0/2017 Form Approved.OMB No.20504039 <br /> UNIFORM HAZARDOUS I 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 4$3-379.8 011583980. F L E- <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if d ffereni than mailing address) <br /> DTE Sunkton LLC <br /> 2526 W.Washington Street 2526 W WasW*on Street <br /> Stodt;ton:CA 95203 Stocicton.CA 95203 <br /> Generators Phone,(2091320-3714 ATTNJesse Levliis <br /> 6.Transporter 1 Company Name U.S.EPA ID Number GA4000 <br /> I _ <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8,Designated Facility Name and Site Address U.S.EPA ID Number <br /> Clean Harbors Buttonwillow LLC C A D S 9 0 6 7 5 27.6 <br /> 2500 West Lokern Road <br /> Fp" illow.CA 93205 <br /> ga 9b.U.S.DOT Descrlption(including Proper Shipping Name,Hazard Class,ID Number, 10.Conta#ners 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 1. <br /> 0; NON-RCRA HAZAROM WASTE.SOLIDS,(FLY ASH) <br /> UJ <br /> 2. <br /> J <br /> C) <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 1 X11116417531 <br /> 15. GENERATOR'S10FFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately descrited above by the proper shipping name,and are classified,packaged, <br /> marked and labeladlplacardad,and are in all respects in proper condition for transport according to applicable international and national governmental regulations,if export shipment and I am the Primary <br /> Exporter,i certify 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)(if I am a large quantity generator)or(b)(if I am a small qL entity generator)is true. <br /> Generator's101f roc s Printed/Typed Name igna ure on ay ear <br /> i <br /> r 16.Intemational Shipfinerts <br /> F-• ❑Import to U.S. El Export from U.S. P9.f. rylexii: <br /> Transporter signature far exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> T porter 1 Printed ;adZarne ISign I on ay e. <br /> i <br /> Day <br /> CJ <br /> 2 � I`S <br /> z Transporter 2 PrinNdrryped Name Signature Month uay ear <br /> 9 <br /> F• <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Spaca ❑ Quanti <br /> ty El Type El Residue El Partial Rejection El Full Rejection <br /> Manifest Reference Number: <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> .r <br /> L� <br /> ►+• <br /> Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month II Day Your <br /> T. <br /> 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Cl 1. 2. 3. 4. <br /> H132 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name � � Signature I Month I Day I )Y`ear <br /> EPA Form 8700-22(Rev.3.05) Previous editions are obsolete. DESIGN,kf-D FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> Clean Harbors has the appropriate perrltits fOF and cells accept the waste the generator is iihipping. <br /> s <br />