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1300 West Kettleman Lane PR0521322 <br /> October 18, 2021 Program: HW <br /> PHOTO 1: Manifest found without a designated facility signed copy. <br /> SEL SK SHIP#229979 391 <br /> SSL SK SHIP#232758452 <br /> not or type. Farm Approved.OMB No.2050.0039 <br /> UNI <br /> F RMHAZARDOUS I.Gmeralor lD Number CAL0002B5559 2.Page]ot 3.Emameaq Rgspogca PlwopO aMan�Tnc,in'��O SK <br /> S ' <br /> 1 WASTE MANIFEST 11 1 ntl0 'roU l 7b t(l, 7 7 <br /> G W,Nameano all Adtlress Gene—Sile Address liftliaerent NenL.arg.o.—, <br /> Rutosone # STA, Autazone N 5682 <br /> Y "ATS <br /> Front Street 1300 W Kettleean Ln <br /> HI5 TN 38103-0000 <br /> cerremrors come: �-339-4459 LODI CR 95242-4571 <br /> 6Y U.S.EPA 11 NYmbe! <br /> }�-"�F°�SYSTEMS INC TXR000081205 <br /> 7.TrenspmrerY DDmpanY Name U.S.EPAIO Number <br /> C1.EAP1 HARBORS ENV SVC INC. MAD039322250 <br /> a Denigrated Fe bName-Sits Address CLEAN HARBORS ARAGONITE, LLC U.S.EPAMNumber <br /> 11606 NORTH APTUS ROAD <br /> aciARAGONITE , UT 84029 <br /> 435-584-5100 ARAGONITE <br /> Flilys Phone: <br /> g, aou.S.D becorobonlirvJWing Proper Shippirg Namell—Closs.ID Number, 10.Containers "army <br /> 12.Unit f3.Waste CDtles <br /> HM atm Patltirg Group lif anyj) No. Type Ouarmy "War. <br /> X ' RD, LIN1993, WASTE FLAMMABLE LIQUIDS DM P F00 Fl 17263 <br /> o N81�, (XYLENES, BENZENE), 3, PG <br /> . I� '7 <br /> Feel D001 223 <br /> z. <br /> w <br /> 0 <br /> a. <br /> 4. <br /> spedalHandlirrmawDmnaaneneaioonailnrom,anon TSD-AS 84641323 AU31468 CSS) <br /> I I)ER(3#128 <br /> i 24H EMERMNCY#800-468-1760–CH/SH/TFI–Contract retained to generator confers a eTom authori - <br /> itionalhalfcl� <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:)hereby declare cal the contents of this wnsignmenlaretally and accurelely descebetl above by Ne proper shlppirg name,aM are classifietl,packaged, <br /> maMed ane Iab,iiNplecorded,and are in all respec6ln properboudition for transport according to applicable intemafionaland national govemmemal raguWgons.It expoM1 shipment ane Ism due Primary <br /> Exporter,l cer01y Nat Vascontents of cis bcnsignmentocnicon to the terms of the attached EPAAcknowledgment of Consent. <br /> j I carythat Bre waste mininnized slabmant identified In 40 CFR 262.27(a)(8 l am a large quantity,generator)or(b)(8l am a small quantity gavemtar)is no, <br /> G—rac e/OBerofs PrintedRyped Name Signature Month Day Year <br /> 9 Y_ij <br /> II /� ._ ) <br /> 18.Inlemaa 1 Ipments ❑Impodm U.S. ❑Expad from U.S. Pm.onrylexit. <br /> r ?Trensporlersignature(forexpuisonly): Dale leaving U.S.: <br /> W 17.TmnspD rAckwMedgmentof Receiptof Materials <br /> y I li a}ler 1 Pnnledrfyp d Name Signature 1 Month Day Year <br /> QTrensportar2 Printed?yped Name Signature I Monlh Day Year <br /> K <br /> 1 � <br /> i18.Discrepancy <br /> 181.Discrepancy Ind..Space ❑Quantity ❑Type ❑Residue ❑Parol RaleNon ❑Full Rale")m <br /> Manifest Reference Number: <br /> Z 1eb.Allemale Fadlity(or Generator) U.S.EPA ID Number <br /> U <br /> LL Fecillys Pincus. <br /> 18c.Signature ofAllemate FadOy(or Generator) Monti DaIs,, <br /> B.Habbi a Wool.Repod Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 23. 4. <br /> 10.Deslgnaled Faculty Omer or Operaor Cerlilwllon of receipt of haumom materials covered by the manifest except as noted In Item 18a <br /> not diced Name Signature Month D <br /> I <br /> EPADgr(@)po 2(ity.11).jI)$us editions are obsolete. GENERATOR'S INITIAL COPY <br /> Lydia Baker, SR. REHS Page 1 of 1 <br />