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Please print or type.(Form designed for use on elle(12-pitch)typewriter.) 714830484 SC PPW 3/3/2011 Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergeney Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000292949 27— wowmn-a71sFLE <br /> 5.Generators Name and Mailing Address Generators SdeAddress(if different than mailblg address) <br /> MCI Inc <br /> PO Bos 725 2500 West Turner Road <br /> Chino,CA 91709 Loi CA 95242 <br /> Generators Phone: <br /> 6.Transporter 1 Company Nam U.S.EPA ID Number <br /> Clean Harbors Environmental Services Inc MAD039392250 <br /> 7.Transporter 2 Company Name U.S.EPAID Number <br /> a d W3 A G1 ZZZ <br /> e.Designated Fsdlity Name antl SdeAddress U. .EPA ID Number <br /> Clean Harbors Aragon a LLC U T D 9 815 5 2 2 7 7 <br /> 16�0I�0r�tNyorltlAtill Road <br /> Fararse,UT 84029 <br /> [A1451 99111100 <br /> gra, 9b.U.S.DOT Description(including Proper Shipping Name,Heard Class,ID Number, 1D.Gemainem 11.Total 12.Unit <br /> HM <br /> and Packing Group(if any)) No. Type Quantity Wtival. 13.Waste Codes <br /> c 1 NON RCRA HAZARIMS WASTE LIQUIDS,(DIESEL.WATERII �d Am 90 343 <br /> ;Y <br /> KtUtlVtU <br /> 3. APR 14 2013 <br /> 4 ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> 14,Special Handling Instructions and Additional Information <br /> 1_CM76096 <br /> �)(✓� ,— Sig <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: 1 hereby declare gad the contends;of tins consignment are fully and aauffiary described above by the xWr shipping name,and am classified,peekingetl, <br /> marked and IabelaNplaarded,and are In all reamers In proper condition for transport according to applicable international and national govemmemal regulations.if"pod shipment and I am the Primary <br /> Exporter,l artily that the contents of this consignment conform to the terms of the attached EPAAcknowledgment ofConsent. <br /> I certify that the waste nininilzafian statement identified in 40 CFR 262.27(a)('d I am a large quantity generator)or(b)(r I am a wag quan8tyganerator)is he. <br /> eamaWs! S ntedRy`ped Name�� � naIll ��month /ay Year <br /> Y7 46 1 <br /> 16.International Shipments `+f <br /> I 12- <br /> 2 Importto U.S. Export trorn U.S. Fort menbylerdC <br /> Trasnassoner s' amre torex ds only): Date lewing U.S.: <br /> W 17.TransporterAdmwAadgwint M Remipt of Materials <br /> Transporter 1 PdrarriTyped Name �9 gnedum Morshi Day Year <br /> a Gni �KO/r-OCA �� <br /> Transporter 2 P.ri-ntedfryped Name tore an ay Year <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication Space El Quantity ❑Type <br /> ❑Residue ❑Partial Rejection ❑Fall Rejection <br /> Mantled Refe ante Number: <br /> 18b.Alternate FadMy for Generator) U.S.EPA to Number <br /> J <br /> V <br /> LL Fadi s Plane' <br /> 18c.Signetue ofAltemate FaciNy(or Demanded Month Day Year <br /> y19.HaK040ifasta Report Management Method Codes(i.e.,codes for hanrdous wasle treatment,disposal,and recycling syslare) <br /> 2. 3. 4. <br /> Facility Owner or Operator.Ced'diwtion of receipt of hazardous materials covered by the rearrest noted in Item IBe <br /> Primed? ed Name a uar Doth Day Year <br /> 127f QfJ <br /> EFA Fortaf 8700-22(Rev.3-05) larevioutis editions obsolete. DE ILITY TO DESTINATIONS ATE(IF REQUIRED) <br /> Clean Hadbers has the apprelliviate permits for and will accept the waste thegenerater is shi"hig <br />