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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) d/ p PPw 10/1 o/zaV Form Approved.OMB No.2050-0039 R <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of3.Emergency Response Phone 4.Manifest Tracking Number a, <br /> WASTE MANIFEST. U-A L 0 0 0 3 5 9 1 0 2 (800)48:3-:37:19 1 1 5 8 3 9 9 . F L E <br /> 5.3enerator's Name and Mailing Address Generator's Site Address(if different than mailing address) i <br /> DTE Stockton LLC <br /> 2526 W.Washington Street 2526 w washini Street 1c <br /> Studtmn.ICA 95203 Stodktan.CA'95203 <br /> GE:nerator's Phone:(2091320-M4 AnWjesrd Lewis <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> A)"J'Ut <=::�W <br /> 7.Transporter 2 Company i U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Clean Harbors Buttomillillow LLC CAD 9 S 0 6 7 5 2 7 fi <br /> .7504 west Lokern Road <br /> B�p�tarillow.CA 93206 _ <br /> Facikly's P one: t <br /> 9a. gb,U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit q <br /> 13.Waste Codes <br /> Hfd and Packing Group(it any)) No. Type Quantity Wt.Nol. <br /> 01 NON-RCRA HAZARDOUS WASTE,SOLIDS.(FLY ASMI Y <br /> ur <br /> a• 2. <br /> ui <br /> �f <br /> Ei <br /> 3. <br /> 4. I <br /> 14.Special Handling Instructions and Additional Information <br /> i..CS6419533 <br /> ,I <br /> 15, GENERATOR'SIOFFEROR'S 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 /> masked and labeW/placarded,and are in all respects in proper condition for transport according to applicable intemational 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 EPAAdmowledgment of Consent. <br /> 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 quantity generator)is true. <br /> Generator'sIOffe is Printedl Typed Name igna ure on ay ear <br /> � i y <br /> _r 1 International Shiptents <br /> �- ❑Import to U.S. Export from U.S. Port ent zit: <br /> 2. <br /> — Transporter signature for exports only): Date leavingU.S.: <br /> uE 17,Transporter Acknowledgment of Receipt of Materials l <br /> Tr o er 1 Printed/Typed Name ignature MonthI ay Year <br /> C; 4 1 <br /> Tmnsper 2 PrintedlTyped NameSignature Month ay Year g <br /> 16.Discrepancy <br /> 16a.Discrepancy Indication Spacey <br /> ❑ Quantity ❑Type E]Residue El Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S..EPA ID Number <br /> .i <br /> Lr <br /> LL: Facili s Phone: t <br /> u� 180.Signature ofA9temate Facility(or Generator) Month Day Year <br /> a; <br /> v� 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 receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Prntedfiyped Name ,l Signature v Month Da Year <br /> EF'A Fors 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 accept the waste the generator is shift pitrd, <br />