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Phase print or type.(Form designed for use on elite(12-pitch)typewriter.) 5' Sc PFW 10/11160/2017 Form Approved.OMB No.2054-6039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST ICA LO 00 35 9102 900 4113 718 011584047 FLE <br /> 5.�eraYor's NO a� idle Address Generator's Site Address(if differeit than mailing address) <br /> t <br /> 2626 W.Washiryptw Street 2526 W Washimmn Soret <br /> SffiS►.r,.A$�5�43 Stn,CA 9520,1 <br /> Generator's Phone:(2091320-3714 ATTNJesse Lewis <br /> 6,Transporter 1 Company Name U.S.EPA ID Number <br /> (YiOdOd _3�4� <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> S.Designated Facility Name and Site Address U.S.EPA ID Number <br /> ':lean Harbors Buttonwillow LLG .. n n ra.. .• c., -..- .; <br /> 22500 WestLoicem Road L-n e.r a a v v e a c r a <br /> 13uttonwillow.CA 93206 <br /> FEcilit esPhone: (6611762-620 <br /> 9`' <br /> 9b.U.S.DDT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HfA and Packing Group(tf any)) No. Type: Quantity Nk.Nol. <br /> c: 1 NON-RCRA HAZARDOUS WASTE.SOLIDS.(FLY ASF!) 571 ` <br /> UJI <br /> u <br /> 2. <br /> i ' <br /> C1 <br /> 3. <br /> 4. <br /> 14,Sectal Handlin instructions and Additional Information <br /> ].. 541753D <br /> y <br /> R, <br /> 15, GENERATOR'SlOFFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are fufly and accurately described above by the proper shipping name,and are classified,packaged, :a <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national govemmenlal regulations.If export shipment and I am the Primary S?, <br /> Exporter,I certify that the contents of this consignment conform to the terms of the ahached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement iden0 ied in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantit,generator)is true. <br /> Generatoesl er is Printed/Typed Name bignature Month ay Year <br /> VZr <br /> _s 16.Intemational Ship nts <br /> �—• ❑Import to U.S. ❑Export from U.S. Port of ntrylep. <br /> Trans iter ' ature for ex its onI Date leaving U.S.: <br /> CC 17 Transporter Acknowledgment of Receipt of Materials <br /> ut <br /> �. Transporter 1 Printed/Typed Name Signature onth Day 7ear <br /> X. Transporter 2 Printed/Typed Nfima Sig MonIn Day Ye r <br /> 18,Discrepancy { <br /> 10a.Discrepancy Indication Space ❑ Quanflly ❑Type ❑Residue ❑Partial Rejection El Full Rejection <br /> a <br /> Manifest Reference Number: <br /> r: Tao.Alternate Facility(or Generator) U.S.EPA ID Number <br /> d; :d <br /> LL, Facilitys Phone: <br /> �j 18c.Signature of Alternate Facility(or Generator) - - Month Day Year <br /> v: <br /> 2: <br /> 5 19 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste atatwt,disposal,and recycling systems) <br /> Cr 1. 2. 3. 4. <br /> H132 <br /> 20,Design ted Facility Owner or Operator:Certification of receipt at hazardous materials covered by the manifest except as noted in Item 18a <br /> ea <br /> I � f" \(A PdntedlTyped Narne Signature Month Day Year <br /> L - t I �11 <br /> EFA Fcrm 8700-22(Rev.3-45) Previous editions are obsolete. DESIGN TF-D FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> Glean Harbors has the appropriate pem*s for and will aosept the waste the generator is swo pulig. ' <br />