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0 <br />.,rasa mint ortvme.fForm designed for use on elite fit-DItch�ewdter.1 .� "��1 !T®"1 Form Approved. OMB No. 2050-0039 <br />EPAForm87UU-22(Hev.3-05) PrevlOUeedlgons8re0Demlete. <br />DESIGNATIO FACILITY TO GENERATOR <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />WASTEMANIFEST CAR000216556. <br />2. Page 1 of <br />-Z/ <br />3. Emergency Response Phone <br />406 768 4966 <br />4. Manifest Tracking Number <br />0094.79260 JJK <br />S. Generator's Name and Mailing Address Generator's Site Address (Kdifferent than mailing address) <br />ECS REFINING, LLC. <br />2222 S.'a1NCLAIR AVE. <br />209 774 5001_ ST,3CKTON�`CA. 95215 <br />Generator's Phone: _- - -' <br />6. Trees odo 1 Company Name U.S. EPAID Number <br />1✓Fs REFINING, LLC. CAD003963592 <br />7. Tra a orter2 Company Name U.S. EPA ID Number - <br />\n chw•+-x <br />8. Designated Facility Name And Site AddretLEAN HARBORS, LLC. U.S. EPA ID Number <br />111::021 <br />EERRYESSA RD. c Ab a 5q N 9 <br />408 451 50.00 SAN JOSE, CA. 95133 <br />Facilltys. Phone: <br />9a <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (I any)) <br />Quantity <br />Wtivol. <br />c <br />NA 3077, HAZARDOUS WASTE, SOLID, N.O.S <br />S <br />� <br />181 <br />(LEAD DE4skiT5), 9, PGIII <br />DSA <br />z <br />2. <br />3. <br />4. <br />14. Special Handling InsWctions and Additional Inform ul n ,r / �` <br />'�'� <br />PROFILE GW5-&- rp,•,) ERG#171 <br />Y <br />15. GENERATOWSIOFFEROR'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 labaledtpiacarded, 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 EPAAcknowledgmenl of Consent <br />I.carlify that the waste minim'vation statement Identified in 40 CFR 262.27(e) (81 am a large quantity generator) or @) (IfI am a small quantity generator) Is We. <br />GeneiamrsrOReror's P,ddnlo Nama� Signature Mob y CZ <br />L <br />r <br />16. Intemational Shipments <br />❑ Import to U.S. ❑ Exportfrom U.S. Port of entryfaxlt: <br />Transporter'signatum (for exports only): Date leaving U.S.: <br />w <br />17. TranspoderAcknowledgment ofReceipl of Materials <br />Transporter 1 PrintecaypedName SignatureMon Day Year <br />���Ir_ �G 91/2 <br />y <br />Jz,55f aS F <br />z <br />Transporter 2 PdntedlTypeq Names �r Signaturd, Month Day Year <br />k� <br />5 ry <br />Fes-' <br />T 1•N�(`n... +,, <br />18. Dlscrepanc? \ <br />T <br />18a. Discrepancy Indication Space <br />❑ Quantity El Type ❑Residue - ❑Partial Rejection El Full Rejection <br />Manifest Reference Number: <br />18b. A6emate Facility (or Generator) U.S. EPA ID Number <br />J <br />U <br />I <br />Faciliys Phone: <br />w <br />18c. Signature ofAltemate Facility (or Generator) <br />Month Day Year <br />Q <br />Z <br />w19. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />Hiyl <br />4. <br />' 20. Designated Facility Owner or Operator. Certl6catlon of recelpt of hazardous materials covered by the manBest except as n*d in Item ills <br />Printed/T Name - Signature `Y1''� Month Day Year <br />EPAForm87UU-22(Hev.3-05) PrevlOUeedlgons8re0Demlete. <br />DESIGNATIO FACILITY TO GENERATOR <br />