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Please print or type.(Farm designed for use on elite(12-pitch)typewriter.} 9Nc6 T-7SC PPw 10/i.0/2017 Form Approved.OMB No.2050-0039 <br /> UNIFORM HA2AR000S 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST C 0 (� 011583991 <br /> LE <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> DTE Stoditn LLC <br /> 2526 W.washirrton Street 2526 w washinift n Street <br /> Stockton.CPI 95203 Stodcton,CA 9620�' <br /> Generators Phone: <br /> 6. ransporter 1 Compan�"i4 <br /> U.S.EPA ID Number <br /> Z000 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated FacUty Name and Site Address U.S.EPA ID Number <br /> ,rl <br /> I'lean Harbors$uttornlrillorr LLC A D 8 $4 6 7 5 2 7 6 E <br /> ,2550 west Lokem Road . <br /> Aflow-CA 832011 <br /> (662 <br /> J. <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,tO Number, 10.Containers 11.Total 12.Unit +, <br /> 13.Waste Codes <br /> HIA and Packing Group(if any)) No. Type quantity Wt.NDI. <br /> 0' 1.NON-RCRA HAZARDOUS WASTE,SOLIDS.(FLY ASH] lescrte,_w <br /> dc <br /> �7 <br /> T 2, <br /> UJI <br /> i7 <br /> s� <br /> 3. <br /> v <br /> t-4-- <br /> 14.Special Handling Instrucb'ons and Additional Information <br /> J._Q641753D <br /> a� <br /> i <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 are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national gove mmental 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. G <br /> I certify that the waste minimization statement identified in 40 GFR 262.27(a) if t ani alarge quantitygenerator)or(b)(if I am a small quantity,generator)is true. <br /> [17. <br /> neratoesl6Pfe rs Printe yped Name Signature on ay Year <br /> 4 10 V9 <br /> —a .Intafnational Ship ents 1:1 ❑ <br /> F,- Import to U.S. Export from U.S. rt of !exit: _ ,r <br /> a` ansporter signature{for exports only): Date leaving U.S.: <br /> F.. <br /> 9X Transporter Acknowledgment of Receipt of Materials <br /> Trm or 1 Pri ed/Type One Mont <br /> ay Year " <br /> G <br /> c- NCZ P.IrL <br /> 2.1 Transporter 2 Printe yped Name Signature Month DeVYet <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity El Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> F- <br /> 18b.Alternate Fac lily(or Generator) U.S.EPA ID Number ' <br /> =i <br /> Ci <br /> .4 <br /> u Facili 's Phone: »� <br /> ui 187 Signature of Alternate Facility(or Generator) Month Day Year <br /> ui19.Hazardous Waste Report Management Method Codes(Le„codes for hazardous waste treatment,disposal,and recycling systems) <br /> CI 1 . <br /> H132 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Ito-7 16a <br /> Prntedffyped Name Signature Month Day .Year <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. DESIGNATE']FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> clean liaribors has the appropriate permits for and will accept the waste the generator is sh'ry►liling. <br />