Laserfiche WebLink
Please print or type.(Farm designed for use on elite(12-1 typewriter.} LIVSC PPW 1114!2017 Farm Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Trackin Number <br /> WASTE MANIFEST CAL 0 0 0 3 5 910 2 l (800)X83-3�i8 011 83990 FLE <br /> 5.3enerators Name and Mailing Address Generators Site Address(if differert than mailing address) <br /> DTE Stockton LLC ! <br /> 2526 W.Washington Street 2526 W Washhoon Street <br /> 5tockton.CA 95203 S <br /> Generator's Phone: > n� 95203 <br /> 6.Transporter 9 Company Name U.S.EPA ID Number <br /> 7.'fransporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number 1 <br /> Clean Harbors Buttonvvillow LLC. <br /> r6 a nnnnr'-r5n -rr <br /> :2500 West Lokerrf Road _ n u a a v e ;r c. 0 o <br /> f3 �tnrillaw.CA 93206 <br /> Fa on <br /> s one: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HIM and Packing Group(if any)) No. Type Quantity Wt.Nvl. <br /> F; NON-RCRA HAZARDOUS WASTE.SOLIDS.(FLY ASH) ! /+ 571 <br /> z: 2. <br /> Ui <br /> y <br /> 3. °A <br /> �a <br /> 4. <br /> > <br /> 14.Special Handling Instructions and Additional Information <br /> i_[�1641753D <br /> 15 GENERATDR'SIDFFERDR'5 CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described at ove by the proper shipping name,and are classified,packaged, <br /> marked and Iabeledlplacarded,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 EPA Acknowledgment of Consent. <br /> I cerci that the waste minimization statement identified in 40 CFR 262.27 a {if l am a <br /> certify ( } large quantity generates)or(b){if I am a small quantity generator}is true. <br /> Generators! rs PrintedlTyped Name Signature Month Day Year <br /> 16 International Shi encs ❑Impart to U.S. ❑Export from U.S. rt of a !exit: _ <br /> 2' Transporter signature(for exports only): Date leaving U.S.: <br /> ui 17 Transporter Acknowledgment of Receipt of Materials <br /> Tmnsporter 1 PrinledlTyped Name Signature Month Day Year <br /> 0 <br /> a. Z Octal. 1 <br /> 2: Transporter-2 Printedi Nameignature o ay ar <br /> d; �w <br /> 18 Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑ ❑Full Rejection }Partial Re'edion <br /> Manifest Reference Number: <br /> 183.Alternate Facility(or Generator) U.S.EPA ID Number <br /> =i <br /> U- Facility's Phone: <br /> ui 18..Signature of Alternate Faal y(or Generator) Month Day Year <br /> z; <br /> 0 19 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Ci 1. 2. 3. 4. <br /> H132 <br /> 20 Designated Facility Owner or Operator:Certification of rete' t of hazardous materials covered by the manifest except as noted in Item 1 Be <br /> PrintedlTyped Name �� � Signature � � Month Day Year ' <br /> tr i <br /> EFA 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 aorept the waste the ii(eneraiof is 5hippini <br />