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Please print or type.(Fort designed for use on elite(12-pitch)lypewdter.)7�i600i075i7 SC PPW i/20/20i0 Form Approved,OMS No.2050-0039 <br /> UNIFORM HAZARDOUS 1.13 rreretor ID Number 2.Page 1 of 3.Emergerxcy ResponsePt re 4.Manifest Tracking Number <br /> WASTE MANIFEST I C AR 0 0 0 2 2 5 5 5 7 :.� (800)48'3-37181 0OPFL E <br /> 5.Generator's Name and Mailing Address Generators Site Address(a different than mailing some <br /> YRC Inc d.b.a YRC Freight <br /> 9 OfI40 Rne Avp 1535 EasctPescadero Ave <br /> Overland Park.115 66211 <br /> Generators Phone: (209118-334300 ATTNJamieHaines TracvCA95304 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Clean Harbors Environmental Service,Inc. MAD 0 3 9 3 2 2 2 5 0 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Clean Harbors Aragonite LLC <br /> 11600 North Aotus Road U T D 9 91 5 5 21 7 7 <br /> Grantsville.UT 94029 <br /> Facipl es Phone: 14391 38w o.x nn <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.To1a1 12.Un'c. <br /> HM and Packi g Group('dany`r) No. Type Quantify cocoa, 13.Waste Codes <br /> 0 UN1993,WASTE FLAMMABLE LIflU1DS,N.O.S.,(ETHANOL. q �� YS 11154 D001 331 <br /> X METHANOL).3.PG 11 l <br /> 2' RFS1QIIF_LAST C:(1NjAIpFQIINi593,Q1CHLflRDMETHANE. 513 <br /> X 6.1.F1G 111 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Aldikk'' nal Informa9on �1J0S$5515 <br /> 1_CF11125995 /k5 Y ERG#126 NVIRONMENTAL HEAL <br /> -2_CH112571O /1(/SDP ERG#16O PERMIT/SERVICES <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accuraky described above by the proper shopig nave,and are classNed,packaged, <br /> marked and Iabeled/placardel,and are in at respects in proper condition for transport according to applicable international and na9onal governmental regulations.Irexpon shipment and I am the Primary <br /> Exporter,I ceN'y that the contents of this consigrvnent conform to the terms of the attached EPA Acknowledgment of Consent. --�. <br /> I ceni y that the waste minhmzation statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(If I am a small quantity generator)is true. <br /> nemloY er rs rint yped me gna re on ay ear <br /> Src1 I-VA J1 zz /G <br /> .r 16.International Shipments <br /> i ❑Import to U.S. LJ Export from U.S. Pon ofentrylexit r <br /> Transporter snature fa ds only): Data leavint;U.S.: I <br /> w 17.Transporter Acknowledgment of Recelpt of Materials <br /> QTrampyy�er 1 Pdnted/Typ Na l gni reg��__�,/.�. an ay Year <br /> Z Transporter 2 Pdntedrryped Name <br /> 10-1 17 <br /> Q awes month ay Year <br /> C <br /> F- <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quentity ❑Type YP ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Rekrence Number. <br /> (= 186.Alternate Faclity(or Generates) Manifest <br /> U.S.EPA ID N'umber <br /> J <br /> U <br /> res+- Factli s Phone: <br /> Q18c.Signatureof Aftemate Facility(or Generator) <br /> Month Day Year <br /> 2 <br /> 55 19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> I <br /> H040 2 H040 3' 4. <br /> 20.Designated Facility Owner or Cperabr:Cer ifirat on of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Sgnaturo <br /> Month Day Year <br /> EPA Form 00- e.3-05 Pre ous editions are bsolete.. LITY TO DESTINATION STATE IF <br /> 81ean�tarliers�lasYheaooroonat°eoef its for and will accept the waste thegejIAWKQ ( REQUIRED) <br />