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P' <br /> k <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) 1 �� SC PPW i0/1.0/20i7 Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST <br /> FLE <br /> 5.Generator's Name and Mailing Address G erator's Site Address('d dilTererl than mailing address) <br /> DTE Sto[irlbon LLC <br /> 2526 W.Washirow Street 2526 W Washin=n Street <br /> Stockton.CA 95203 Stodrton,CA 9520ij <br /> Generator's Phone: ?., <br /> B.Transporter 1 Co pan arae U.S.EPA ID Number <br /> r CAe0601y9. -y <br /> 7,Transporter 2 Company Na U.S.EPA ID Number <br /> f is <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> I'Nean Harbors Buttonwillow LLC CAD 9 9 0 6 7 5 2 7 6 <br /> 2Z�ab4 WestLokem Road <br /> F%*% illUW'CA 93206 <br /> (66t4 7-62-6200 <br /> +, <br /> ya 9b.U.S.DOT Description(Fnciudirg Proper Shipping Name,Hazard Class,10 Number, 10.Containers 11.Total 1 12.Unit 13.Waste Codes <br /> HIA and Packing Group(if any)) No. Type Quantity Wt.1Vol. n <br /> x <br /> n= 1'NORACRA HAZARDOUS WASTE,SOLIDS,tFLY ASH) _ <br /> `u j 2. d <br /> 1 <br /> 3. <br /> u <br /> 4. <br /> la.Special Handling instructions and Additional Information <br /> IL_CH6417535 <br /> �5 <br /> At <br /> 1E. GENERATOR'S10FFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described aiwve by the proper shipping name,and are classed,packaged, <br /> marked and labelediplacarded,and are in all respects in proper condition for transport according to applicable internationai 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 certify that the waste minimization statement identified in 40 CFR 262.27(a)('d I am a targe quantity generator)or(b)(if I am a small quantit?l generator)is true. F <br /> .neratoesl0ifer s Print yped Name igna ure n ay ear <br /> _u 1E.International Ship encs <br /> F_ ❑Import to U S. ❑Export from U.S. FAof= <br /> Transportecsignature(for exports only): Date leaving U.S.: <br /> edgment of Receipt of Materials <br /> 0 Trilsparte Prnte yped Name gnature on ay Year <br /> s <br /> c5 n <br /> G_ <br /> eCTransporter 2 PrintedlTyped Name ignatu nt Day Year <br /> oc D 0 <br /> F_ Y=' <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantifyy <br /> ❑T pe El Residue ❑Partial Rejection ❑Full Rejection <br /> 'c <br /> Manifest Reference Number, <br /> �= 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> CD <br /> K <br /> �- Facility's Phone: <br /> u� 18c.Signature ofAltemate Facility(or Generator) Month Day Year <br /> 10.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> a 1. 2. 3. 4, <br /> Hi32 . <br /> 211.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 16a <br /> Pintedffyped Name Signature / Moe, Daffy Year y <br /> f � G <br /> E'A Form 8700-22(Rev.3-051 Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> Clean harbors has the appropriate permits for and will accept the waste the generator is shipping. <br />