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SSL :K SHIP# 2351231"19 t t Porn+Approved,OMB No.2050-0039 Please print or type. 4.Manifest TracM{ng Number UNIFORM tfAZARDOUS 1.Generator ID Number CA!)1�49293A71 2.Page 1 of 3.Er4er�e�cy�e�s��11796 C SKS WASTE MANIFEST 1 1 q J �l J 008 5.Generaloes Name and Mailing Address Generator's Site Address(if different than mailing address) Ineredion Inc Inorenz:.ln Inc P box 6129 Attnit otoer Hoffflahl 16[1 Inuustrial Dr :K I ON twit T-;.21 6—V104i lid CA 95EIA6--391'6 Generators Phone b29—a STOCKTON 6 ransppdetlCom�anyN@me , U.S.EPA ID Number r?ntWlrj�91 �� '. r_t Y r1..tt ry SY S�Gn{5 I Nil 7.Transporter 2 Company Name U.S.EPA 1D Number CLEAN HARBORS ENV SVG INL. �H 039s�22aS� B.Designated Facility Name and Site Address CLEON Hi i' _'•'ill,;3 uikk:)s 11%1-'i'1!`]TCAIN U.S,EPA ID Number 3 MILES Eii,,zJ, 7 MILES I`:urt"H KNOLLS EXIT 41, OFF I-80 KNOLLS , UT �t`r'rlt:� !<TTl3'�L30J,748 �►3a-8194-951 5 a Facility's Phone: ya 9b.U.S.DOT Description(including Pieper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit 13 Waste Codes HM and Packing Group(if any)) No. Type Quantity Wt.Nol. X 1-IN043062, HAZARDOUS WASTE LIUUI[l, r, P D004 D006 3007 o N.G.S. (CHROMIUM, LEADI, 9, PG III LU 2 3 a 14.Special Handling Instructions and Addibonal Information I SD:13 r! 871141255 C079848 9848 1)tRG#I71' 24H ENERGENCY#800-468-1760-CH/SK/TFI-uuntract retained by generator confers anency authori} on initial tra:i; rt r t adr i t ` nia - r•j _ _�, ,, 15. GENERATOR'SIOFFEROR'S CERTIFICATION; I hereby declare that the contents of this consignment are fully and accurately descnbed above by the proper shipping name,and are classified,packaged, marked and labeledlplacarded,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 conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 26227(a)(if I am a large quantity generator)or b)(if 111-a small quantity generator)is true. Geneato sl0ffero s Printed/Typed Name Signature// Month Day Year ,j 16.IntetTiational Shipments F ❑Import to U.S. ❑Export from U.S. Port of entrylexit ?I Transporter signature(for exports only): Date leaving U.S.: W 17 Transporter AcknoWedgment of Receipt of Materials Transporter 1 PrinledlTyped Name Signature Month Day Year C> z Transporter 2 Prfntedrryped Name Signature } Month Day Year F 18.Discrepancy 1Be.Discrepancy indication Space ❑ Quantity ❑Type ❑Residuej 1 ❑Partial Rejection Full Re'ection Manifest Reference Number. 18b.Allemate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: ,LU 18c.SignatumofAltemateFacility(or Generator) Month Day Year Q Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) 7:1 G 1. 2. 3. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Pnntedlryped Name Signature Month Day Year EPA Form 6740 (Rev,12-17),Previous editions are obsolete. GENERATOR'S INITIAL COPY