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530948-22 ERI Provider: Clean Earth 4939552 <br /> Please print or type.(Form designed For use on elite(12-pitch)typewriter.) <br /> NONHAZARDOUS 1 Generator IONumber 2 Page t of 3 F.mergercy ReW.rse Phone 4.Waste Tracking Number <br /> WASTE MANIFEST CAR000223776 1 (877) 577-266 5 3� 1�{ 'OZ p1 <br /> (r5 Generators Name and Mailing Address Generator's Site Address,,it different than mail ng address) <br /> 60 Hone 9epot C/O PSC Rttn. Hope Depot CSI "M Depot 6661 <br /> O 5251 Triangle Partwy, Spite 2 16 2968 I EMUS RAMCH PARY1' <br /> 4 Generator's Phone PEACHTREE CORNERS 6A M92 (2141263-6117 LODI CA 95241 <br /> 6 Transporter t Comoany Name U S EPA!�Number <br /> 11 CLEAN EARTH SPECIALTY WASTE SOLUTIONSNMS000110924 <br /> 7 Transporter 2 Company Name US EPA 0 Number <br /> 8 Designated Facility Name and Site Address t1 S EPA ID Num4er <br /> Clean Earth Specialty Paste Solutions - Iancho <br /> 3311 Fitzgerald Road <br /> Faalrt's Phone. Raecho COrdmre, CA 95142 1916) 225-1121 CAL000467839 <br /> 9a gb U S 007 Descnpl,on orduding Proper Shiopgrg Name Hazaro >ass v vur to 10:;ontalne's t t Total 12 Ung <br /> HM and Packing Group!,l a(,,z, <br /> No Type Quantity NI,Vol <br /> 0 11001) TREATED 9001 URSTE - to Mot Win or Scavenge 1 Ch 10 Y <br /> ga <br /> w <br /> z <br /> w <br /> 4 <br /> 13,Special Handling Instructions and Additional Information <br /> 111 MWPTV-11 - PRESS1K TREATEI Y00 DSS <br /> 14 GENERATOR'S CERTIFICATION: !certifv the materials describer,above or this manifest are not suhiea to federal regulauors for reporting proper disposal of H zardous Waste. <br /> Generat r'sioBeror's Printed/Typed N me Signa"ure Month Dav Year <br /> C! !`lVr �t t1 � 2,"1122- <br /> _J 15.International Shipments <br /> porter sl nature or exports only)" <br /> nl.,...� p Export from U S <br /> ?ions nt entry,ek t <br /> g po y) <br /> Import to U pa <br /> .;ate ea,rrg U.S <br /> LU 16.Transporter Acknowledgment of Rpoer t of Matera!s <br /> � <br /> Tran er t P"Ied,7 edv N Signature Month nav Yea= <br /> CL <br /> anJ z <br /> rn <br /> Z Transporter 2 Printed yped Name <br /> 5gna''r° Month Day Year <br /> H <br /> 7.Oiscreparcy <br /> 17a.Discrepancy Ind,callon Space; � <br /> ouanNy �yoe ....1 Residue _� <br /> 1_ ,Partial Relectvtn t,, ,Ft;ll RP1eGhon <br /> Manifest Reference Number <br /> "` Alternate Facility for Generatai J S EPA 10 Number <br /> J_ <br /> rJ <br /> LL Facility's Phone <br /> C3 17c Signature of Alternate Facility for Gereratorl <br /> Q Month Clay Year <br /> Z <br /> S2 <br /> y <br /> w <br /> 18 Designated Facility Owner or Operator Cerlification of rece,pt of malenals covered by the manifest except as noted n Item 17a <br /> priotedTyped Name <br /> �,,�I��r ', S,grature Month Oay Yea, <br /> 6•NHM.C•C-11 rjVprr- <br /> "-DESIGNATED FACILITY TO DESTINATION <br />