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Please'_infor type. (Form designed for use on elite (12 -pita., _,,rewrite. �CJIYI3929 PM 27)2W7 Form ADnroved CIMR Nn 7050-0o3q
<br />Clean Harbors has the appropriate peffy is for and will accept the waste We generator is shipping.
<br />UNIFORM HAZARDOUS
<br />WASTE MANIFEST
<br />1 Generator ID Number
<br />C A. L B 0 0 1 4 4 7 1
<br />2. Pae 1 of
<br />3. Emer ency Response Phone
<br />(l ) 4s�3718
<br />------ ----
<br />4. Manifest Tracking Number
<br />0 0 0 971180
<br />F L E
<br />5. eneraAt ( Nab$,agd, Iiingg /guess Generators Site Address (if different than mailing address)
<br />San Joaquin Cotm Solid Waste Dais, PO Box i8i© 1333 East Turner Road
<br />Stockton, CA �620i Lodi, CA 95240
<br />Generators Phone: 24$ 48$-300 ATDJ: Kirl Andrem
<br />6. Transporter 1 Company Name U.S. EPA ID Number
<br />Clean Harbors Env Services Inc M A Q d 3 B 3 2 2 2 5 4
<br />7. Transporter 2 Company Name U.S. EpA�Q,N
<br />8. Designated Facility Name and Site Address J /d�r, ,� s^ :,� !s`i, U.S. EPA ID Number
<br />aciRy's Phone' �"! f
<br />ga
<br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number,
<br />and Packing Group (if any))
<br />10. Containers
<br />11. Total
<br />12. Unit
<br />13. Waste Codes
<br />HM
<br />No.
<br />Type
<br />Quantity
<br />Wt.Nol.
<br />1:AEROSOLS , 2. 1, UN 1$50 �e�T 5",P /� d'�/�`
<br />6`12
<br />".
<br />L
<br />-
<br />Z
<br />2 -PAINT REt_ATED MATERIAL, (OUBASED PAIN -n .3. UN 1263. PC
<br />612
<br />0
<br />x
<br />II
<br />'FLAMMABLE SOLIDS, ORGANIC, 11 ,0 S., (RESINS, AUHESVES
<br />812
<br />X
<br />(HI VxF)) , 4.1, USI i 325, PC, III
<br />P423
<br />frxry�
<br />4 TfJ IC: SOLIDS, ORGANIC, N.O.S., (METHYL CARBAMATE,
<br />812
<br />X
<br />PYRETHRINS (HHV4,)), C.1, UN2611, P1.j I,
<br />1
<br />14. Special Handling Instructions and Additional Information
<br />1. GHQ-•. 2•ry`r�fsr3. CIi2d0617.�W��•��
<br />2. ewH24t;a 5 i51Av4. CH440623 f .�i��✓eL'� "
<br />�7 t,
<br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described a ove by the proper shipping name, and are classified, packaged,
<br />marked and labeled/placarded, and are in all respects in proper condition foMransport according to applicable international and national governmental regulations. If export shipment and I am the Primary
<br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent.
<br />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.
<br />eherator's 0 erorr'/s PrintedlTyped Nameignatuulre Month Day Year
<br />Z
<br />16. International Shipments
<br />❑ Import to U.S. ❑ Export from U.S. Port of entry/exit:
<br />-
<br />Transporter signature for exports only): Date leaving U.S.:
<br />W
<br />17, Transporter Acknowledgment of Receipt of Materials
<br />L
<br />Transporter�1 Pririnted/Typed�NNaame Signature a _ Month
<br />' - Daay Year
<br />Z/
<br />Tra orter 2 PnntedlTyped,Name ignature, ; % i ., - Monk.► rD, Y
<br />H
<br />l�� 'C✓ ..-''' !/ r�' jF �'
<br />18. Discrepancy
<br />18a. Discrepancy Indication Space El Quantity El Type D Residue El Partial Rejection El Full Rejection
<br />Manifest Reference Number:
<br />18b. Alternate Facility (or Generator) U.S. EPA ID Number
<br />J_
<br />V
<br />Q
<br />LL
<br />Facili 's Phone:
<br />w
<br />18 ignture of Alf$rnate F2cTty (o[ Generator) Month Day Year
<br />Z
<br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems)
<br />LLI
<br />1. M1
<br />t r
<br />2.
<br />��
<br />3.
<br />4.
<br />20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the m st except as noted in Item 18a
<br />Pri t /Typed Name ure Mori D�0 Year
<br />EPA Fo Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR
<br />Clean Harbors has the appropriate peffy is for and will accept the waste We generator is shipping.
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