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Generator acKnowleGgef that no material change has occurred either In the characteristics or in the process gent"In <br /> Please print or type. 04 :OMB No.206OM39 <br /> UNIFORM HAZARDOUS 1.GeWAX ID Number 2.Page 1 of 3.Emergency Response Phone 14.MwWW"ed T ng <br /> WASTE MANIFEST N O N E R E Q U I R E D 3 (800)4$3-3718 015225788 ELE <br /> s.?ra4 nV WnVa Inc GeneraWs sas�admsaa rt d rent man mrew,g sadness) <br /> 99 Southbound Frontage Rd SAME <br /> Stsocittom CA 95215 <br /> Generators Phone:(209190-8209 <br /> 6.Transporter 1 Company Name U.S.EPA 10 Number <br /> Clean Harbors Environmental Services,Ino. MAD 0 3 9 3 2 2 2 5 0 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and She Address U.S.EPA ID Number <br /> Clean Harbors 6tft>rtn —R— LLC CAD 9 8 0 6 7 5 2 7 6 <br /> 2500 West Lokem Road <br /> Bumwwillow,CA 93206 <br /> Fad a Phone: (6611762-6200 <br /> 9a. 9b.U.S.DOT Dexliption(including Proper Shpping Now,Hazard C1aea,ID Number, 10.Containers 11.Total 12.Unit 13.Wasta Codes <br /> HM and P1k*ng Grout(d ant)) No. Type Quantify MJW. <br /> 0 1 NON-RCRA HAZARDOUS WASTE.SOLIDS,(DIESEL al SOIL) �M Q 352 <br /> z 2. <br /> W <br /> 0 <br /> 3. <br /> 4. <br /> 14.Soadaltiandlirxilnstrucbons and Ackitonal Irdor ration <br /> Contract retalnetl b 4eaeritor conhrs agent <br /> w4ftority on initial ttwwWer to add or substitute adttitiontad i <br /> 15. GENERATOR'SdOFFEROR'S CEI F'1CATiON: I Nnby dedare that the oontenb of this consignment are fully and aoarrably described above by the proper shipping name,and are desrred,padmged, <br /> marked and labeledlpfacaded,and aro in all respects In proper mrdibOn for ha"W accordng tu appkabie intar atiarelad national gover vwtW regubtlons-M eVort shone t and I am the ftnory <br /> Exporter,I ovbfy that the oonlante of this consigment oordorm b the terms of the attached EPA Ackr avladgmeM of Consent <br /> I cert y M 8e waste mnimlzabon statament identified in 40 CFR 26227(a)(if I am a large quantity generator or(b)(if 1 am a small quantity genw obr)is trre. <br /> Generabralgb oes Pnnr dff)psd Name Sig Month Day Year <br /> ,j 16. tonal ShOnents <br /> ❑Import to U.S. Export from U.S. Port of ertryJendt: <br /> = Transporter signabe(tor Up"only): Dale leaving U.S.: <br /> ej 17.Transporter Adnoniedgmwd of Receipt of Malerieb <br /> Transporter 1 Prirtedfryped Name Slgnatire Day Year <br /> W 2 ZiD <br /> Tr mporbr 2 PrInlediTypeeName Signature Month Day Year <br /> 18.Disuepancy <br /> 18a. screpancy Indicatlon Space El ❑Type ❑Res due ❑PaUd ReJegbn ❑Full Rejeobort <br /> D <br /> Manifest Reference Number: <br /> 18b.Alterna a Faniity(or Generator) U.S.EPA ID Number <br /> V <br /> f Fadliys Phone: <br /> aW 18c.Signature of Alternate Facility(or Generator) Monro Day Year <br /> 2 <br /> 19.Hazardous Wasle Report Management Method Codes(i.e.,codes for tracardous isle tream ant.disposal,and recycling systerns) <br /> C 1. 2. 3. 4. <br /> H132 <br /> 20.Desgnated Fadiy Owner or Qperelx Cer�Yrr@Wn of moW d hazardora matens covered by to manifest exceptw rdled in Ibm 188 <br /> P Na ign Da Year <br /> N N\t I� Vz9ba <br /> EPA Form 87 2 (Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e•MANIFEST S STEM <br /> Clean HarW6 has the appropriate pemdts for and will accept the vests the generator Is shipping. WSC 2003090009-002 PPW <br />