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J- 4P 9.304827674-A)0-1 IVlc— nrint nr fvrw iP v n riwginnari fnr uga nn AMP 119_nitnial tvrwAv(dar.) -K, PPW (4 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. // 9,WMNATED FACILITY TO DESTINATION STATE (IF REQUIRED) UNIFORM HAZARDOUS [I. Generator ID Number Ar�CS5�0 0 2 9 G 14 713 2. Page 1 of � 3. Emergency Response Phone T011848923 + Manifest Tracking Number FLE WASTE MANIFEST 1 14x3-371 5 Oun m rouse a er f reatment Plant Generator's Site Address (if different than mailing address) 19045 Kelso Road SAME Mountain lRali- lm Generator's Phone: Transporter I Company Name U.S. EPA ID Number Clean Harbors Environmental Seraices, Inc. M A D o 3 5.3 2 2 2 5 0 7. Transporter 2 Company Name U.S. EPA ID Number 6. dY ame and Site Address U.S. EPA ID Number -- -14111,113NME44fAb, BAKERSFIELD TRANSFER CAL0002$E53o 1620 E_BRUNDAGELANE Bakersfield. CA 93307 Fedl s Phone: ( 6611 322-9259 ga_ 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group Cd any)) Quantity WWol. 1N0N-RORA HAZARDOUS WASTE, LIQUIDS, (DESEL, WATER1 343 z 2. W CD 3. 4. l4. S ?A— 11 1q-! a[b Additional Information 1 + Ms 8'11 C —\s1�` Go�wact retained by cens=or cnnfers aGa:1ev a0*nonty on initial trans[:oRe, to add QF 5!J0StrLge 3ddit anal Va soorters or, hehaK 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of Mus consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 26227(a) (if I am a large quantity generator) or (b) (9.l am a small quantity generator) is true. GeneratwWOfferoes n meigna on ay Year ft_/1 b F 16. International Shipments ❑ Import U.S. ❑ Export from U.S. Port of entrylexit Z Transporter signature for -I Date leaving U.S.: Cr W 17. Transporter Acknowledgment of Receipt of Materials � T 1 Print yped Name na re on y ear Transporter PrmtedlTyped Name Signature Day ear 1 18, Dbcrepancy 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number. 18b. Alternate Facility (or Generator) U.S. EPA ID Number V a u- Facilitys Phone: 18c. Signature of Altemate Facility (or Generator) Month Day Year Z Z H19. Hazardous Waste Report Management Method Codes (Le., codes for hazardous waste treatment, disposal, and recycling systems) G 1. 2. 3. 4. 20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item laa Name Signah5e Month Day Year rL I/ U 1 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. // 9,WMNATED FACILITY TO DESTINATION STATE (IF REQUIRED)