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SK SHIP4 P2=6460 <br /> ok <br /> P,leap jnt or pe,(Form designed for use one lite(12 pitch)typewriter.) Form Approved,OMB No.2050.0039 <br /> ORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4,Manjfest 7rackln Number. <br /> WASTE-M4NIFEST <br /> L 6137 'SKS <br /> 5;Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) ; <br /> A A - Bolden Dat ADD A Golden Sate, <br /> A0501 Btt rod A . .19 eeel Mchenr'y l" anford d <br /> TRACY CA 95377 A to Lester, Sabo <br /> Generators Phone:, . 7�F �1+ C 77 , <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> A A L SYSTEMS IN <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARSORS.ENVIROMMENTAL 8W INC. A <br /> 8.Designated Facility NaTo' nd Site Address U.&EPA ID Number <br /> CLEAN HARBORS GRASSY MOUNTIN <br /> 3 MILFS EAST9 7 BILES NORTH KNOLLS EX14£9 WF,. i4io <br /> KNOLLS �UT 84083 <br /> Facilitjrs Phone: <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM .and Packing Group(if any)) Na Type Quantity Wt.Nol. <br /> 0 1 W N Lt A WA D WASTE SOLIDS (NON AN t> aye <br /> 0 RCR HAZARDOUS SOLID (ADS NT <br /> AND 01L <br /> z 2. <br /> W <br /> 3 <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSS g N 74877 S g <br /> H EMERGENCY 4(1-8 -458-17613 (CH � . K JT(=T� ._ ���`� � ,��� � <br /> 6 . 1< <br /> 15. GENERATOR'SIOF.FEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully,and accurately described above by thb p opershipping name,and areclassified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If exportshipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> [certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(ig am a small quantity generator)is true. <br /> GeneratofslOfferofs Printecirryped NameSlg lure Month Da Year; <br /> ' . 1 " <br /> Z 16.In(emational Shipm is ❑Import to U.S." ❑Export fr m U.S,t Port of entrylexit <br /> = Trans'porter signature(for exports only): s Date leaving US r <br /> W 17.Transporter AcknowledgmentpfReceiptofMateriats <br /> Transporter 1 Pnnted/Typed Nam Signature Month Da Year` <br /> O <br /> Z Transporter 2 Printed .0 Name Signature <fr-, -I Month Day Year, <br /> tL' , 1461 <br /> 18.Discrepancy <br /> 18a.Discrepancy.lndication Space El'Quantity ❑Type EIResidue ❑Partici Rejection Full RejecGoh <br /> "Manifest Reference Number. <br /> 18b.Alternate Facility or Generator) U.S.EPA ID Number <br /> J <br /> Facility's Phone: <br /> El 18c.Signature of Alternate Facility(or Generator) Month.. Day Year <br /> 0 19.Hazardou Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1• 2. 3. 4• <br /> 20.Designated Facillty,04er or Operator.Certification of receiptof hazardous materials covered by the manifd except as n i d m 18a <br /> n r <br /> Prints yped Nam SignaIre[ <br /> 111t � <br /> EPAFo 8 00-22(Rev.3105),Previous editions are obsolete. pESIGNATED FACILI.TYTO'GENERATOR <br /> 10171—r "A t 5 I I <br />