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Please print or type.(Form designed for use on elite(12-pitch)typewriter.)48 1502395283-002 SC PPW 7!4!2015 Form Approved.OMB No.2050.0039 UNIFORM HAZARDOUS 1.Generator ID Number _ 2.Page 1 of 3.Emergency Response Phone 47 i t T u WASTE MANIFEST CAL 0 0 0 3 1 9 0 8 5 j 1800}483-3718 t 1`t' 8`8 O 1 FLE 5.Generator's Name and Mailing Address Generator's Site Address(if different than mating address) Lathrop City of 2112 East Louise Avenue SAME Lathrop.CA 95330 Generators Phone: (209)441-7442 ransperer 1 Company Name U.S.EPA ID Number Clean harbors Environmental Services Inc MA D 0 3 9 3 2 2 2 5 0 7.Trarsporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name anc Site Address U.S.EPA ID Number Clean harbors Buttonwillow LLC 2500 West Lokem Road CAD 9 8 0 6 7 5 2 7 6 Buttotrwillnw.CA 93206 Facility's Phone (6611762-6200 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if ary)) 13.Waste Codes No. Type Quantity WWd. 1 NON RCRA HAZARDOUS WASTE SOLIDS,(RLTERCAKE 00 SLUDGE) 2 LUI i 3. yy 1 t 4. i 14.Special Handling Instructors and Additional Information 1_CH605767B 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and Iabeledlplacarded,and are in all respecs in proper condition for transport according to applicable international and natonal governmental regulations.N export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAdmowledgment 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. eneralor's/Offeror's Printed! on y Year igue J 16.International Sn ments ,— Z ❑Import to U.S. ❑Export from U.S. Pod of ent Transporter si nature for exports only): Date leavin U.S. rY '7.Transporter Acknowledgment of Receipt of Mate is s LE Transporter 1 PrintedfTyped Name Signature ! onth ay ear �r / Wit- :;16- Z a Transporter 2 Pn dedfTyped Name ign ure Month Day Year H 18.Discrepancy 18a.Discrepancy Indication SpaceEl Quantity El Type ❑Residue ❑Partial Rejection L,I Full Rejection. Manifest Reference Number: 18b.Alternate Facility(or Gererator) U.S.EPA ID Number J_ U Q +L Facility's Phone: W 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z W 19 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 1 H132 2 3. T- 20 Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrirtedfT6�95iii ed NamSignature Month Day Year Olt EPA Prev ous editions are obsolete. DESIGNA ED FACILITY TO DESTINATION STATE(IFR QUIRED) cleanHarbors as tie appropriate permits for and will accept the waste the generator is snipping_