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Please print or type.(Form designed far use on elite(12-pitch)typewriter.) [ Form Approved.OMB No.2050-0039 <br /> UNWORM HAZARDOUS 1.Generatar ID Number 2.Page 1 of 3.Emergency Reaportse Phone Manifest Tracking Number �( <br /> WASTE MANIFEST R T- 0188122 <br /> LS JJ K <br /> 5.Generator=s Name and Mailing Address Generator's SveAddress(ffditent than mailing address) <br /> Nalco Company-Logistics Safety <br /> 1601 W.Diehl Road 5475 Sot�tr� alt Vtia <br /> Naperville,IL B#3563 USA Stockton,CA 95206 USA <br /> Gensrator's P't,one: 830-305-19$2 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> F.Tfanspoder 2 Company Name U.S.EPA ID Number <br /> 8.Designated r'acll'V Name and Site Address Clean Harbors Et Dorado,LLC U.S.EPA[D Number' <br /> 309 American Circle ARD069748192 <br /> El Dorado,AR 71730 USA <br /> Foci sty s Phone: 870-863-7173 <br /> oa. 9b.U.S.DOTDescdpton(including Proper Shippfng Name,Hazard Class,ID Number, 1C.Containers 11.Totat 12.Unit <br /> HtA and Paci ttg Group(if any)) 13.Waste Codes <br /> NO, Type Quantity Wt lVol. <br /> 1. UN2465,Dichloroisocyanuricacld,dryordichlorolsocyanuricacidsatts 1 Q 458 P 352 <br /> 0 51,PGiI <br /> (Contamiarlted absorbents with Nalco Towerbrom 060) <br /> z 2. <br /> 3. <br /> 4. f� <br /> I <br /> IC Specs;€?andlktg Instructions and Additional information <br /> 1.Proffrfe*CHI 238154(ane(1)55-gallon drum) <br /> Order#:1602658288 Alert*20160629-DDI <br /> 15, GENERATOPWOFFEROR'S CERTIFICATION: I hereby declare gnat the can eats of this consignment are fully and=Urately described above by the proper shipping name,and are cisss;,W,packaged, <br /> maeked and labale&placarded,and are in all respects in proper condi;on toy transyorf according to applicable internatfonafand natfonaf gDvamrnental fegulailons.if export shiJiment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I cergy ttratthe waste minimization statement ident Pied in 49 CFR 262.27(a)(it i am a large quantity generator)or if I am a small quanfrtygenerator)is true. <br /> GertemloeslOfferoes PA&dFryped Name Signalu Mori Day Year <br /> Daniel A.Motisi on behalf of Nalco <br /> 16.fn€ernavor4 S%pn;ents <br /> F— ❑Import to u.s. ❑Export from U.S. PQ:t4f erdrylaxl1: <br /> Z Transporter signafure(for exports oMft Date leavt:rg U,&; <br /> w 17.TmnspogerAc)w.v*fedgmenl of Receipt of Materials <br /> Transporter 1 PrintadFFypad Name <br /> Signature 9 Mouth Day Year <br /> 0 <br /> Q Transpoder2PdntedgypedName Signalure Nion8t Day Year <br /> F <br /> 18.Oiscrapancy <br /> 182.Discrepancy Wt Caticn Space ❑ Quantify ❑Type ❑Residue ❑Partial Rejection <br /> l ❑Fcll Rejec€ion <br /> Manifest Reference Number. <br /> 18b.Aitema'wFac2ity{arGeneraior) U.S.EPA[D Number <br /> iJ - <br /> L FaeiliVii Phone: <br /> Lu 18c.Slgnafu se of Alternate Facility(or Generator) tAonsh Day Year <br /> Q <br /> 19.Hazardous Waste Report h'lanagement Method Codes(€.e.,codes for h nardoLG waste treatment,disposal,and recycling systems) <br /> 1. 2. 3. 4. <br /> 20.Desgnatad Facif,.ty Owner or Operator:Cer6Ecat[on of receipt of hazardccrs materials covered by the manifest except as noted in€tem 182 <br /> Pdnted(Typed Name Signature Mon£h Day Year <br /> BPA Foran$700-22(Rev.3-05) Previous editions are obsolete, DESIGNATED FACILITY TO DESTINATION STATE-(IF REOUIRED) <br />