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Please pdnt or type.(Farm designed for use on elite(12-pitch)typewriter.) $v �d SC PPW '0/iO/2017 Form Approved.OMB No.2050.0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number _ WASTE MANIFEST CAL 0 0 0 3 5 9 1 0 2 � I8UO1483�-3719 011583982 FLE_ _ 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) DTE Smckton LLC 2526 W-Washington Street 2526 W Washin,;;mn Street Gentoekton.CA 95203 Stodcmn,CA 95203 is 320-3714 AMN-Jesse Lewis 6. ransporter 1 Company Name U.S.EPA ID Number &Ail 64k 00w15`Y31-3 7.Transporter 2 Company Name I U.S.EPA ID Number 8.Designated Facility Name and Site Address US.EPA ID Number Clean Harbors Buttonwillow LLC: CAD 9 B O fi 7 5 2 7 fi 2500 West Lokern Road F ifty 's ofi ne:kM-CA 93246 ga 9b.U.S.D07 Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt./Vol. 1. NON-RCRA HAZARDOUS WASTE.SOLIDS,(FLY ASH) m T a 2. Lll CM 3. 4. I 14.Special Handling Instructions and Additional Information 1.CH641753B 15. GENERATOR'SIOFFEROR'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, marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.4 export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. 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 qt artty generator)is true. Generator's10 rs Printedffyped Name signature Monffi Day ear _r 16.Intemational Shi ents F•• ❑import to U.S. ❑Export from U.S. I&oftrylexit: Transporter signature for exports only): Date leavin U.S W 17.Transporter Acknowledgment of Receipt of Materials Tr iter 1 PrintedlT ed Name ig u Month Day ear U) er 2 Printedfiyped Name atureMonth Day Ybar r� I I I 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection Full Re'feIlion ❑ Manifest Reference Number: F.: 18b,Alternate Facility(or Generator) U.S.EPA ID Number .i C;i 1 4 LL• Facilit's Phone: W 18c.Signature of Alternate Facility(or Generator) r Month Day Yoar z 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) Ci 1. 2. 3. 4. H132 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as n in Item 1 Ph !Typed Nae Signature Month Day Year X 6115 1/ EPA Porhi 8700-12{Rev. -05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIREb) Clean Harbors has the appropriate pem its for and will accept the waste the A neater is!;hipping-