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4B 11,904827674-00-1 K.PPW 7/i'-1/20191W <br /> lease print or type.(Form designed for use on elite(12-pitch)typewriter.) -s" .2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Plane 4.Manifest Tracking Number <br /> WASTE MANIFEST A�s's�0 0 2 9 6•i 4 7 3 1 (80014$3-3718 011848923 FLE <br /> SMOUfl sin I10U5e aTer I reatrnent Plant Generators Site Address(if different than mailing address) <br /> 18045 Kelso Road SAME <br /> Mountain ggam. lm <br /> Generator's Phone: <br /> 6.Transporter I Company Name U.S.EPA ID Number <br /> Clean Harbors Environmental SeMces,Inc. M A D 0 3 9.3 2 2 2 5 0 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Design try and Site Address U.S.EPA ID Number <br /> •,.••• VWAh-,' <br /> .'BAKERSR ELD TRANSFER C A I_0 0 0 2 8 2 5 9 30 <br /> i620 E BRUNDAGE LANE <br /> Bakersfield.CA 93307 <br /> Fadr s Phone: f66il 322-9258 <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Paddng Group(d any)) No. Type Quantity WUVol. 13.Waste Codes <br /> Ix 'NON-MCRA HAZARDOUS WASTE,UQUIDS,(DESEL,WATER1 343 <br /> 1 TT coo 6- <br /> Z 2. <br /> W <br /> 3. <br /> 4. <br /> 1 5qa-- DwTe Additional Information <br /> c�J �B\ot°k51�� <br /> C°mtract retatneG by aen_ratcr confers mencw authority on initial transoole:to 3d-1 ,?r suDslWe add(t oral ir3'isoorters of asneratcr' eenalf <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeledlplacarded,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 <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)Of I am a large quantity generator)or(b)(9.I am a small quantity generator)is true. <br /> Gerwator'90fleroes Pdntodffyped Name Siiinabire Month ay Year <br /> 16.International Shipments <br /> I— ❑Import U.S. El Export from U.S. Port of entrylexit <br /> 3 Transporter s4wture for exj n Date leavng U.S.: <br /> 1Z 17.TransporhxAdmowledgment of Receipt of Materials <br /> Tra 1 Print yped Name na re y Year <br /> g <br /> Transporter 2 PrfntedlTyped Name Signature Day ear <br /> 16.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> Q <br /> � Fadi' s Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> � <br /> 1. � 2. r <br /> 4. <br /> H11 1 <br /> 20.Designated Facility Owner or operator.Certification of receipt of hazardous materials covered by the manifest except as noted in Item t as <br /> yp�Narthe Signa Month Day Year <br /> U lot-Ili <br /> EPA Form 8700-22(Rev.3-05) Pr vious edili=Vare obsolete. 6ZI 9EV6NATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />