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/?0/5 eO$ F-7 <br /> Please print or type.(Forth designed for use an elite(i2 pitch).iypewriter. SC PPW 10/10/2017 <br /> Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2,Page 1 of 1 3.Emergency Response Phone 4.Manifest Trackin Number 1 a. <br /> WASTE MANIFEST GAL 0 0 0 3 5 9 1 0 2 (800)4833718 011 8 0 4 fi FLE <br /> 5.Elf C�r Address Generator's Site Address(if different than mailing address) S <br /> 2526 W.Washianon Street 91K9A ur imachi.e-M!, <br /> Stockton-CA 95203 Stockion.CA 9520;`s <br /> Generator's Phone:(209]320.3714 ATYNJesse Lewis � <br /> 6.Transporter 1 Company Name II� U.S.EPA ID Number <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Ulean Harbors Buttonwillow LLC CAD 9 B O 7 5 2 7 <br /> ,2500 West Lokern Road <br /> Butttonwillow-CA 93206 <br /> F2cili s Phone: (66i1 200 g <br /> ge, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers11.Total 12.Unit <br /> HfA and Packing Group(if any)) No. Type Quant ty Wt.Nol. 13.Waste Codes <br /> n. 1 NON-RCRA HAZARDOUS WASTE,SOLIDS.(FLY ASH) 571 <br /> A� y� <br /> ul ydd <br /> ur <br /> 2. � <br /> u 1 <br /> 3. <br /> s <br /> 4. <br /> t <br /> 14.Sectal Handiin InstrucbOns and Additional Information <br /> s_�Is417�s35 <br /> 15. GENERATOR'SIDFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fulfy and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labelediplacarded,and are in all respects in proper conditon for transport aocording to applicable mtemational and national gove,nmental 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 252.27(a)(d I am a#arge quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generator's eroe Print yped Name igna ure Month Day Year <br /> 16,InternationalShipment <br /> ❑Import to U.S. ❑Export from U.S. Port entry it:_ f <br /> Transporter signature for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> a <br /> :Trarspo 1 PrinledlTyped a rgna ort ay ear <br /> Transpo r 2 PrintedlTy Name SignatGre Month Dgy 7@7- <br /> 1 B. <br /> ea18.Discrepancy <br /> 1U.Discrepancy Indication Space Quantity ❑Type ❑Residue ❑Partial Rejection ❑Fut!Rejection <br /> Manifest Reference Number: <br /> 18t.Atemate Facility(or Generator) U.S.EPA ID Number <br /> Facility's Phone: tl <br /> FW— 18e.Signature otAllernate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Uj t2. 3. 4. <br /> H132 <br /> ED—Facility Owneror Operator:Certification of rece€pt of hazardous materials covered by the manifest except as noted In Rem 18a <br /> tedlTyped Name 1- Signature Month Day Year <br /> �..� 11411 LAI tq <br /> EPA Form 8700-22(Rev.3-05) Previous editions are obsolete, DESIGN EG FA ILITY TO DESTINATION STATE(IF REQUIRED) <br /> Clean harbors has the appropriate pemits for anil wiN accept the waste the xewrator is s'�re(Nrr <br />