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"'No Violation #'s l 1S & 116 — — 46 002395283-002 -Sr,FPW 71`412015 Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050.0039 UNIFORM HAZARDOUS 1 Generator ID Number 2.Pae 1 of 3.Emergency Response Phone 4. I t Tyl9�u�lp�` WASTE MANIFEST C A L 0 0 0 3 9 0 8 5 1800)493 3718 u Mitt O�+Q 1 FLE 5.Generator's Narre and Mail ng Address Generator's Site Address(If different than mailing address) Lathrop City of 2112 East Louise Avenue Latt>it CA 95330 Generators Phone: (2091941-7442 Transporter 1 Company Name U.S.EPA ID Number :lean Harbors Environmental Services Inc MAD 4 3 9 3 2 2 2 5 0 7.Transporter 2 Company Name OctU.S.EPA ID Number 8.Designated Facility Name and MeAddressU.S.EPA ID Number Clean Harbors Buttonwillow LLC ENVIRONMENTAL HEALTH 2500 WestLolcem Road DEPARTMENT CAD 9 8 0 6 7 5 2 7 6 guttonwillow.CA 93206 Facility's Phone: 1`6611762-6200 9, 9b.U.S.DOT Desvoan(inclu&kgl Proper Shipping Name,Hazard Class,lD Number, W.Containers 11.Total 12.Unit 13.Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 1. NON RCRA HAZARDOUS WASTE SOLIDS,(FILTER CARE 161 1 ) o SLUDGES z 2. y I 4. e 14.Special Handling Instructions and Additional Information 1.CH60,9767B 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this cons gnment are fully and accuraWy described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conforn to the terms of the attached EPAAcknowledgment of Consent. 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. Geneiato,'s10 era's rioted ype Namengna ure Month Uay Year 3 –J 116.International ments C— ❑Import to U.S. ❑Export from U.S. Part of envood,: Z Transporter signature for exports only): Date leaving U.S. w 17.Transporter Acknowledgment of Receipt of Materials Trte'1 Primed(Typed Name Srgnalure _ on ay Year Transporter2lon tedlTypedName Signature Monti Pay Year 18.Discrepancy 188 Discrepancy Indication Space ❑ Quantityyp j j 11T e Residue ❑Partial Rejection Full Re ec8on r Manifest Reference Number: F 18b.Alternate Facilily(or Generator) U.S.EPA ID Number J_ U I Facility's Phone: C3 18c.Signature of Alternate Facility(or Generator) Month Day Year d Z 19 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1LLJ . H132 2 3. a. 20 Designated Facility Owner or Operator:Certification of receipt of hazardous materiels covered by the manifest except as noted n Item 189 PnrtedlTyped Name Signature Month Day ��Year rhAA L& I yt-�qyL EPA orm 800.22(Re 3-051 Pre v�ous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) C can a ors alas the appropriate permits for and will accept the waste the generator is snipping.