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611603281226-0(d SCPPW 7/20/2015 Please pent or type. (Form designed for use on .,fife (12 -pitch) typewriter.) Form Approved. OMB No. 2050.0039 1 G e ato IDJdu b� 2. ge 1 of 3. qg@ Rffi4&Pn PhDr]P. 4. Mi nffest Tracking Number UNIFORM HAZARDOUS C L b [I 6 �i 4 4 3 9 4 1 �Ui%�4:f,� X517 L3 n O O Q'5Q% 1 n F I- E 1_LCCRQ ERG#1215 1X30 2_LCCRD ERiG#128 5X55 3 _ LrCCR$ ERG#15 4 1X30 _ by the Proper shipping name, and are da: ified, packaged, 15. GENERATOR'StOFFEROR'S CERTIFICATION: I hereby ded are that the contents of this consignment are fully and accurately described a hove and are in all respects in proper condition for transport according to applicable international and national governmental regulations If exportsh0ment and I am the Primary marked and lebeledlplacarded, Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Adrn a oleo or b Consent. t ama small quantiy generator' Is true. I cerGty that the waste minimization statement identified in 40 CFR 262.27(a) (f I am a large quantity 9 n2r ) O (if on ay � 4 International Shipments ❑ Import to U.S. I_J Export frog U % Port of z t F— ( Date leaving U.S.. ? Transporter sinature for exports onl: — 17. Transporter Acknowledgment of Receipt of Materials gar m r� z Transposer [ rriniea i,rpc„ .a r n i ct 18. Discrepancy ❑ Residue ❑ Partial Rejection iBa. Discrepancy Indication Space ❑ Quantity Type Manifest Reference Number. U S. EPA 10 Numher 18b. Alternate Fadtity (or Generator) J v _1 LL Fadli s Phone: — C3 I F Slgnature of Alternate Facility (or Generator) 4 z 19. Hazardous Waste Report Management 14ethod Codes (i.e., modes for hazardous waste Treatment, disposal, and reading systems N =HO40 30 t2 040 H040 20, Designated Facility Owner or Operator: Cert licafion of receipt of hazardous materials covered by the m(ndeest except as noted in Item 18a nat re ❑ Full Rejection Month Cay Month Cay, Printedd_rT peName 9 I28� EPA Form 870 -22 (Rev -05) revlous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) Glean Ha ors has the appropriaTe permits for and wit{ accept the rUaste the orator 15 5hlpplrl. WASTE MANIFEST — 5. Generator's Name and Mailing Address v i3aneratoes Site Address (itddferent than mailin(address) Ferguson 630 POrtOf &tadcton St SAME Stoddun.CA 95203 I Generator's Phone: . Transporter 1 Company Name _ U.S. EiPAtD Number Clean Harbors Environmental Service. lna _ _ MAD 0 3 9 4t 2 2 2 5 0 _ 7. Transporter 2 Compan ame �� r� u h U.S. EPA ID Number � � — """ 8. Designated FadlityName and Sde Address U.S. EPAID Number Clean Harbors Aragonite LL.0 U T D 9 81 5 5 21 7 7 11600 North Aptus Road Idle. UT 84029 _ Fadi - y A'5=VC2Sj4I (;1:90 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11. Vial 12. Unit 13.Waste Codes Que!l WtNol. HM and Packing Group V any)) No. Type _ o 1' UN1950, WASTE AEROSOLS. 2.1 0 0 1 _ D F 0 0 0 6 5tPz 2. UNi993. WASTE FLAh�1Bl E L{QU IDS, N_O.S., (ACETONE, 005 D035 D M 015 $1 P METHYL ETHYL KEYTONEi_ 3_ PG 11 _ X I 3. UN3266,WASTECORROSIVE LIQUID. BASIC.INORGANIC, OOi D002 5 1 _ DF 00120 P N.OS._(SOUMHYDOXIDE-SODJUMHYPOCHLORITEI.S_PG X _ —DF 4. 0002 551 UN3264, WASTE CORROSIVE LIQUID. ACIDIC, INORGANIC, 00i _ 0 0 2 49 P x N.O 6.. (DESCIIILER, SULFURIC ACIDI, S. PG II _ FLEU0 5547 1_LCCRQ ERG#1215 1X30 2_LCCRD ERiG#128 5X55 3 _ LrCCR$ ERG#15 4 1X30 _ by the Proper shipping name, and are da: ified, packaged, 15. GENERATOR'StOFFEROR'S CERTIFICATION: I hereby ded are that the contents of this consignment are fully and accurately described a hove and are in all respects in proper condition for transport according to applicable international and national governmental regulations If exportsh0ment and I am the Primary marked and lebeledlplacarded, Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Adrn a oleo or b Consent. t ama small quantiy generator' Is true. I cerGty that the waste minimization statement identified in 40 CFR 262.27(a) (f I am a large quantity 9 n2r ) O (if on ay � 4 International Shipments ❑ Import to U.S. I_J Export frog U % Port of z t F— ( Date leaving U.S.. ? Transporter sinature for exports onl: — 17. Transporter Acknowledgment of Receipt of Materials gar m r� z Transposer [ rriniea i,rpc„ .a r n i ct 18. Discrepancy ❑ Residue ❑ Partial Rejection iBa. Discrepancy Indication Space ❑ Quantity Type Manifest Reference Number. U S. EPA 10 Numher 18b. Alternate Fadtity (or Generator) J v _1 LL Fadli s Phone: — C3 I F Slgnature of Alternate Facility (or Generator) 4 z 19. Hazardous Waste Report Management 14ethod Codes (i.e., modes for hazardous waste Treatment, disposal, and reading systems N =HO40 30 t2 040 H040 20, Designated Facility Owner or Operator: Cert licafion of receipt of hazardous materials covered by the m(ndeest except as noted in Item 18a nat re ❑ Full Rejection Month Cay Month Cay, Printedd_rT peName 9 I28� EPA Form 870 -22 (Rev -05) revlous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) Glean Ha ors has the appropriaTe permits for and wit{ accept the rUaste the orator 15 5hlpplrl.