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712906365 <br />Please print or type. (Farm designed for use on elite (12 -pitch) typewriter.) <br />SC PPW 3/5/2010 <br />Form Approved. OMB No. 2050-0039 <br />EPA Form 5042 (Rev. 3-05) Previous editions are obsolete. L--BCSII <br />Clean Harbors has the appropriate permits for orad WIN accept the Waste <br />ED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />is shipping, <br />UNIFORM HAZARDOUS t GeXrtff8 yuT0 6. 8 8 7 2 <br />G A L V V O <br />2. Page 1 of <br />1 <br />3. ��a074 ti e° <br />"'^Oto 0 2 3 9 3 4 M W <br />MANIFEST <br />(W�aA,aS�TtE� <br />5. 7earSieaT ft`! dress Gen hi SdeAddress (Ndifferent than mairg address) <br />3333 Beverle Rd Bid[ 85348A 2650 North Macarthur Drive <br />Hoffman Estates, IL 60179 Tracil95376 <br />!84712869616 ATTN:Dawn fess <br />Generators Phone: <br />Tr Won n�� NT Services Incu.s.M <br />s. Number <br />AIDD 0 3 9 3 2 2 2 5 0 <br />7.Tmnspormr$ Company N U.S. EPA ID Number <br />�✓ <br />Gf ABy <br />6. 1= HarborsFedFh Name and SNB Address U.S. EPA ID Number <br />Bum nwilowLLC <br />25O0West LokemRoad CA099O675276 <br />&MIB Wllillow. CA 93206 <br />Fadity's Phone: 16611762-6200 <br />ga <br />go. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Trial <br />12. Unit <br />13. Waste Caries <br />No. <br />Type <br />HM <br />aM Pacldrg Group (Navy)) <br />Quantity <br />M.Nol, <br />1 NE- NON RIM HAZARDOUS WASTE LIQUIDS. MAM <br />291 <br />343 <br />PAINT), N/A <br />00 <br />1 <br />PM <br />,5z <br />z <br />2 <br />W <br />3. <br />4. <br />141oaclaLHe94%inshu W Additional Informal <br />15, GENERATOR'S/OFFEROR'SCEKnFICATION: I hereby declare that the contents of this consignment are fury and aureately deal above by the proper shipping name and are classified, packaged, <br />marked and labeledlplaarded, and are in all mspecla In proper condition for transport ao irg to applicable internal enaland national governmental regulations. If export stlpment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAdunwledgment of Consent. <br />I certify that the waste minimization statement identified in 40 CFR 262.27(a) it I am a large quantity generator) or (b) if am a ema6 quantity generator) is true. <br />'nledlr�ed Name SignaWre Year <br />J G.}h lyis y,� <br />J <br />f— <br />16. ntemational5hrpnenb <br />❑ImpM to U.S. mU.e. Pon ofenoy/exN <br />2 <br />Transporter signature nor exports only): Date leaving U.S.: <br />w <br />17. TansporlerPcknoxledgnent of Rea'rytof Materials <br />C <br />Transporter f PrinteCRyp�ed Signal re <br />Month Day Year <br />g <br />�Namn <br />TY1NW <br />v EXO 03 JrO <br />QTransporter <br />2 Printed me Signal re Month Day Year <br />1 6127 VQ <br />16. Discrepancy <br />18e. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑ FuH Rejection <br />Manifest Rehi Number <br />181. AdemateFadlily (or General US. EPA ID Number <br />J <br />V <br />rai <br />Fanlil Phone: <br />w <br />18c. Signature of Atremate Faulty (or Generator) <br />Ml Day Year <br />6 <br />19. Hazardous Waste Report Management Method Codes (ice., codes for hazardous waste treatment, disposal, and recycling systems) <br />o <br />t. HIM <br />2. 3. <br />4. <br />20, Designated Facility Owner or0peratenertifmtionofreaiptofhazardausmalaialsw"mdbythe pt nl fee <br />Printed/I' S' Manm Day Year <br />li Dl 6 J <br />EPA Form 5042 (Rev. 3-05) Previous editions are obsolete. L--BCSII <br />Clean Harbors has the appropriate permits for orad WIN accept the Waste <br />ED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />is shipping, <br />