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ORDER 0 491136 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Ndmber 2.Page 1 of 3.Emergency Response Phone4.Manifest Tracking Number <br /> WASTE MANIFEST C A L,0 0 0 0 4 0 9 4 2 1 . 119100-335-303" 1004864579 JJ K <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> STOCKTON USD STOCKTON USD - S TAGG H.S. <br /> 1944 N. EL PINAL DRIVE 1621 BROOKSIDE DRIVE <br /> STOCKTON, CA 95205 �} n STOCKTON, CA 95207 <br /> Generators Phone: <br /> 6.Transporter 1 Company Name U.S.EPA 10 Number <br /> HARBORS,ENV.S .IN IM A D 0 3 9 3 2 2 2 5 0 <br /> 7. n r n ame U.S. AID <br /> B. ame and Site Address 6,S,EPKId Number <br /> CLEAN HARBORS ARAGONITE <br /> 11600 NORTH APTUS ROAD <br /> ARAGONITE, UT 84029 U T D 9 8 1 5 5 2 1 7 7 <br /> Facility's Phone: 901-323-860 <br /> ga 9b.U.S.001bescdption(including ProveShipping Name,Hazard Gass,ID Number, 10,Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) `1 No. Type Quantity Wt.Nd. 13.Waste Codes <br /> cl� 1(SODIUM ILICATE), S. D002 <br /> " B, UN1760, PG IZ, (S 159) 0u1 — - 003oU <br /> 141 <br /> Z 2. <br /> LU <br /> 0 <br /> 3. <br /> 4. <br /> 14.S eclat Handlin Instructions and Additional.Infit rrnation <br /> CH3�9599 (1 D� sg jj��,,F� <br /> PLACARDS PROVIDED B CARRIER/SHIPPER YES/NO DRIVER SIGNATURE <br /> **** ER CALLER MUST IDENTIFY UNIVAR USA AS REGISTRANT **** <br /> *****PROJECT NUMBER: P025009 JOB START DATE: 1-27-09***** <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accuratelydescribed above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and arein all respects in proper condign for transport according to applicable intemational and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this cons nment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement entified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a sm II quant ty _erator)is true. <br /> Generator,slOfferoes Printedrryped Name Signature Month Day Year <br /> 16.International Shipments <br /> ❑Import to S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> I <br /> CC 17.TransporterAcknowledgment of Receipt of Mate'is <br /> Transporter 1 PrintediTyped Name Signature Month Day Year <br /> a flip f a� 2 0 <br /> Z T nted/T Name ' S gna Mo ye <br /> Q <br /> F- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication pace ❑ Quanillity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> uQ. Facility's Phone: <br /> W 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> Q <br /> 2 <br /> 0 19.Hazardous Waste Report Management Method es(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. � 3. 4. - <br /> 20.Designated facility Owner or Operator.Certification of receipt of hazardous materials covered manifest except aced in Item 18a <br /> Prin edrT ed Nam na Month, Day Yea <br /> EPA Form 8700-22(Rev.3-05) Previous editions a e obsolete. DESIGNA ED E(IF REQUIRE ) <br /> 10538.2012 -" <br />