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6JR 170506662"02 SC PPW 6/28/2017 Please orint or tVDe IForm designed for use on elite (12-oitch) tvoewnler.) Form Approved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. M5) Previoylt editions are obsolete.TED FACILITY TO DESTINATION STATE (IF REQUIRED) Clean Harbors has the appropriate permits wa a for and wit accept the the generD r ship UNIVORM HAZARDOUS 1. Generator ID Number 2. Page 1 of T3 Emergency Response Phone 4. Manifest Tracking Number CAL 0 0 0 3 4 4 3 9 4 (800) 483-3718 011219849 FLE WASTEMANIFEST OrI 6j2ailing Address Generators Site Address (if different than mailing address) 5 Periej rr er 530 Port of Stockton EVy SAME Stockton. CA 95203 Generators Phone. (2091943-9360 6. Transporter 1 Company Name U.S. EPA ID Number Clean Harbors Environmental Services, Inc- IMAD039322250 7. Transporter Company Name � ^ ' U.S. EPA ID Number 1 8. Designated Facility Name and Site Address U.S. EPA ID Number Spring Grove Resource Recovery Inc- e% „ „ ^ r ^ 4-1� A J- „ n 4879 Spring Grove Avenue v n Lj v v v o Loo e-,7 Cincinnati. OH 45232 Facility's Phone ffij -M GM JR729 ga 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11 Total 12. Unit HM and Packing Group (if any)) Quantity WLNoI 13 Waste Codes No. Type 0 1 NON DOT REGULATED MATERIAL, (NON RCRA WASTE) 135 003 D M 00634 P _} i z 2. w 3. I 4. 14. Special Handling Instructions and Additional Information 1.M—NoaRCRA Was 3X55 15. GENERATOR'S/OFFEROR'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 labeled/placarded, and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment 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. Generatoes/Offeroes PrintediTyped Name Signature Month ga—y ear RICH DECKER ON BEHALF OF r10 ii 17 j 16. International Shipments Import to U.S. ❑ Port 1--0 Expo, from U.S. of entry/exit Transporter signature for exports only): Date leaving U.S.: IX W 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed(Typed Name Signature on ay Year H RICH DECKER I 4Z12 10 11 V Q Transport r 2 Pnnted/Typed Name S Month Day Year 1 1101/711 1°c f �� 18. Discrepancy 18a. Discrepancy Indication Space Quantity El Type E] Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J U Q LL Facility's Phone: W 18c. Signature of Alternate Facility (or Generator) Month Day Year Q Z 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) LU LU 1 H 141 2. 3 a. 20. Designat Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Sign Qey r Year ature M Printed/Ty`a Yu7 EPA Form 8700-22 (Rev. M5) Previoylt editions are obsolete.TED FACILITY TO DESTINATION STATE (IF REQUIRED) Clean Harbors has the appropriate permits wa a for and wit accept the the generD r ship