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it <br /> Please print or type.(Farm designed for use on elite(12-pitch)typewriter.) S"BO SC PPW 10/f LO/200 Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS I 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4,Manifest Tracking Number <br /> WASTE MANIFEST F E <br /> 5.Generator's Name and Malting Address G eraiors iia Address{if differe it than mailing address) <br /> DTE Sbx*ton LLC <br /> 2526 W.Washington Sweet <br /> SWckWn.CA 95203 2526 W Washitt n Street <br /> Generator's Phone: Pt1]3' 041.1 A AIMlosaeJ.ewis St�odrtt m A 9520:1 <br /> 6,Transporter 1 Company Name , U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA fD Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Clean Harbors Buttonwillow LLC 4 A D�3 8 0 6 7 5 2 2 6 ' <br /> ,2500 West Lokern Road <br /> Fk%"Q*llow.CA 83206 <br /> 9b.U.S.DOT Description me udin ro er i m Name,Hazard Class,ID Number, 10.Containers x <br /> ga, P { 9 P pP 9 11.Total 12.Unit 13.Waste Codes <br /> HILI and Packing Group(if any)) No. Type: Quantity Wt./Vol. <br /> 1. <br /> 0 NON-RCRA HAZARDOUS WASTE.SOLIDS.(FLY ASH) 571— <br /> 21 2. <br /> w <br /> C) <br /> jl <br /> 3. <br /> �C <br /> 4. <br /> 14.Special Handling Instructions and Additional Information <br /> 1_CR641453)b <br /> x <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I herebydeclare that the contents of this consignment are full and accurate) described above b the proper shi Fn name,and are classified,packaged, <br /> ' <br /> 9 Y Y Y P P PP 9 P 9 <br /> marked and labelediplacarded,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 fb}(if I am a small quano,generator)is true. <br /> enerator'sI rs Printed/Typed Name Signa ' ay Year <br /> _r 16.International Ship ants Ex ort from U.S. ort of nt /exit:_ <br /> F- ❑Import to U.S. ❑ p ry el <br /> Transporter signature(for exports only): Date ieaving U.S.: <br /> X 17,Transporter Acknowledgment of Receipt of MaterialsLL <br /> 9 Y a, <br /> Tr,ins iter 1 Pr ntedlT ed Name Signature Month a Year <br /> co <br /> IT Transporter 2 P-nnted/TypedAame 7ignatu month Day Year <br /> 18.Discrepancy E <br /> 189.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> LL. Facility's Phone: _ <br /> ui 18,.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z: <br /> C, <br /> ui 19 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) A <br /> Ci 1. 2. 3. 4. <br /> H132 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materiais covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> 119 )A <br /> Ll S tF <br /> EFA Fumn 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> Glean Harbors has the appropriate permits for and will accept the waste thegenerator is shilviaL <br />