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�G <br /> �� � SC PPW 10/i D/20V Form Approved.OMB No.2050-0039 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) 2 Page 1 of 3.Emergency <br /> 1.Generator ID Number g y Response Phone 4.Manifest Tracking Number <br /> v, <br /> UNIFORM HAZARDOUS CAL 0 0 0 3 5 91 0 2 1 ($00)4$3-371801150003092 F LE <br /> WASTE MANIFEST <br /> 5.f' at rs=Name Mail! Address Generator's Site Address{if d"arena an mailing adds <br /> i] s�tadctr►n LLC? <br /> '2526 W.WashinAnn Street '7%19 W WaekirtidMr%Q1V <br /> �,.ari.a rr as M.ra.el y�rY1.�++��+-• <br /> 'Wdinn.CA 95: 03 fuckton,CA 95203 <br /> Generator's Phone: U.S.EPA ID Number y+, <br /> 6.'Transporter 1 mpany Name <br /> f U.S.EPA ID Number <br /> 7.rransporter 2 Company Name <br /> U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address <br /> 1:lean Harbors Buttunwillow LLC G A u 9 3 0 6 7 5 2 7 6 <br /> :2500 West Lokern Road <br /> �ilkmr.CA 93205 <br /> 9<r. <br /> 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12,Unit 13.Waste Codes <br /> HIVI and Packing Group(if any)) No. Type Quantity t. <br /> 1 NON-RCRA HAZARDOUS WASTE.SOLIDS.(FLY ASH) <br /> 4I-ral 0-0' <br /> .r <br /> re -' <br /> Lu <br /> ■ 2. <br /> tau <br /> 0 s <br /> 4 <br /> 14.Special Handling Instructions and Additional Information <br /> 1_tM44175315 <br /> 5. 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 arra classified,packaged, <br /> marked and labeledlpiacarded,and are in all respects in proper condition for transport according to applicable international and national go rernmental 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 certify that the waste minimizaWn statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quanl ity generator)is true. n Uay Year <br /> r,errerator'sl rs rinte yp Name igna re <br /> ��44 <br /> A antomatiohnal Ship encs ❑Export from U.S. Port entrylexd: <br /> � ❑Import to U.S. <br /> Transporter Signature for ex orts onl Date leavin U.S: <br /> [L 17.Transporter Ackn iedgment of Rece' tenals om a ear <br /> Y 'fransporter me ype ame igna re �j! <br /> a- Month Day Year <br /> ZTransporter 2 Printedffyped Name ignature <br /> 18.Discrepancy <br /> 18a.Discrepancy indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> U.S.EPA ID Number <br /> F 18b Alternate Facility(or Generator) <br /> J_ <br /> Q <br /> uQ. Facility's Phone: Month Day Yea, <br /> 18c.Signature of Alternate Facility(or Generator) <br /> Q <br /> Z <br /> 19.Hazardous Waste Repoli Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems} <br /> tut 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 Mom Day Yearr <br /> 7— <br /> Printed/Typed Name Signature <br /> A4 1 1 Ll L <br /> EP�kform 8700-22(Rev.3-05) previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> clean Harburs has the appropriate permits fW and WiN aeeept the waste the generater is shipgiw— <br /> y <br />