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Please Prim arriNirf `° acknovr1f ocies that no maledal change has occurred either In the character6i or In the process flenerai ncFbAved. OMB No.20M.0039 <br />EPA Form 571)Ui (Rev.12-17) Previous editions are obsolete. 1. DESIGNATED FACILITY TO EPA's e•MANIFEST SYSTEM <br />clean Harbors has the appropriate permits for and will accept the Waste the generator isshipping. Ci1792407131922-00 PPW <br />UNIFORM HAZARDOUS <br />1. GemrXor ID Number <br />2. Page 1 of <br />3. Emergency Response Phone <br />4. Me Ife�yl <br />T IIIlpl <br />g u r <br />WASTE MANIFEST <br /><_ A C 0 0 3 3 2 4 9 2 7 <br />800 483-3718 <br />+ <br />7 <br />1 997 F L E <br />5. Generator's Nam and Mining Address GenirabR Site Address 0l different( =ling Wfress� n <br />(leanHarborsEnvironmentalServices,Inc "i U " GG(( r�0 <br />2050 West Freemont Street, -WE Ik ion{e eAr C Ay Cis 33 6 <br />Sil}W&`f 95 r'r3 <br />egt Pan Name IJ� / J U.S. EPAID syn „ <br />6 mxmr <br />(i MID IIf` (rte / I <br />7 Transporter 2 Company Nam U.S. EPA ID Number <br />e. Designated Facility Name and Site Address U.S. EPAID Number <br />Clean Harbors Grassy Mountain LLC LIT D 9 9 13 01 7 .} <br />3 Miles East 7 Miles North of Knolls <br />FW lle. UT 94029 <br />lie, <br />%. U.S. DOT Desai Proper Name, Hazard Class, ID Number, <br />and Packing Group (If airy)) <br />10. Containers <br />11. Toul <br />12. Unit <br />13. Ween Codes <br />No. <br />Type <br />HM <br />Quantity <br />VVLNol. <br />o <br />I <br />. UN3432, POLYCHLORINATED BIPHENYLS. SOLID. 9, PG III, <br />) <br />oto) <br />G� <br />fii <br />X <br />WITH 399 PPM F'CBS CCtwtA tL) <br />, —, <br />K <br />' <br />W <br />2c <br />3. <br />4. <br />t4. Special Handmig Imwrllons and Addlional Information <br />1-CH2907262 EPGi171 C N <br />/ n <br />SO a550981yqcr <br />G';ItU3G tel2lheo G+ fOHalOt coo err'. 30 ncp <br />N C A I ,'F ' p M '1 F aAn - U Is'tzin'A] � MaleiulyJ':tfa nctitlm. Bad a .f>>R , <br />marked and labeled/placmded, and are in all restarts in proper condition far transport according 10 applicable intemationaland national govemmenial regulations. If export shipment and I am the Primary <br />Exporter, I cerbly that the contents of this consignment conform to that terns of the attached EPAAcknowledgment of Car nl <br />I cerdly that she waste minimhagon statement Identified in 40 CFR !927(a) (if I em a terga quantity generator) or (b) (' am sma qu' Idly arta r) Is true. <br />aP.falar5lki ra'SP Ypad ami <br />ame SgnaNro MUFyh Wy Year <br />IN <br />F <br />11 In1emabonal Shlpmenb <br />❑ Import to U.S. ❑ E Pal of entrylardt <br />M <br />Transporter signature (for exports only): Date leaving U.S., <br />17. Transporter AcknwAedgme (of Receipt of Matedds <br />Ponspodo M4M/Typtxl NameSom one Mo1}IA De "no <br />x4nC <br />r <br />a <br />cry <br />1/(,/ 11 r <br />Trahsporler2 PMWyped Name sgmlure Month Day Year <br />1e. Discrepancy <br />188. tltsaemmxy Indication Space ❑ Quantity ❑ Type ❑ Raw p�y ❑ Partial Rated. I ❑ Ful Rated]. <br />` <br />01 A'-0 U`x. CLA UccW 1421 4j5Z..Cf I ---Manllosl CK1U c r>r/ o oAp) PST" <br />j%, Ralerenco Nmlboc <br />1Bb. AMmalo Facility (or Crerrrebo'Per �m ��1 ;n U.S. umber <br />�Fe,:,iet <br />cl ritty SO }O YCC;1vQ1'C/7vniksf w-jih �Oev V'dCkO ci Vgll 5 i <br />ua- <br />achly's Phone' <br />w <br />18c. Signature olNlemate Facility(or Generator) <br />Month Day Year <br />S2 <br />19. Hazardan Waste Report Management Method Codes Ili codes fa hazardous waste treatment, disposal. and recycling systems) <br />G <br />1. <br />2. 3 <br />4. <br />20. Designated Facility Owns or Operator: Certification of receipt of hazardous materials covered by the manifest except as Med In Item 7)0 <br />1H132 <br />AmledRyped Namsipnoture <br />Maar Day Yee <br />1 M e ( Z -L;" Z,ss <br />EPA Form 571)Ui (Rev.12-17) Previous editions are obsolete. 1. DESIGNATED FACILITY TO EPA's e•MANIFEST SYSTEM <br />clean Harbors has the appropriate permits for and will accept the Waste the generator isshipping. Ci1792407131922-00 PPW <br />