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JIEV I� tP <br /> Please onnt or�Pe (Form des rued for use on shle(12-pitch)Iypewmtar.) FormA <br /> IpMyed.OMB Na,2A51 OD39 <br /> UNIFORM HAZARLIOU5 I t Gerlerelol ID Number 2 Pape 1 of 3.Emergency Rom some Phone a.Nam m&tq NwWw <br /> WASTE MANIFEST CA2890090002 I' <br /> 92S-11-3-F.-205 Q JA <br /> 3 GenereWs Nar1+e and Maastg AQQress GemeraloYs S:1e Address(d dHrererd Sham mahV addressp <br /> Laurr"_ ce rermerY P�lat,�wa La craeary 5 to 30I (c• ",last La m—..ce Lwe-torr rtaLena3 Laburswv S-te 300 fcr r4r4SA <br /> F 0. E_x Rpa ;L.7a6 L'.errcre r-.."• ?.3551. vr-a: F)a,err Raaf Tarr CA 351YF <br /> Generators Ptmne 425-x11-19-15 A74 SL lv;r$, <br /> 6.TramsporW 1 Company Name U.S.EPA ID Number <br /> Clean Harbors Environmental Services Inc. MAD0393221-7% <br /> 7 Tramsporler 2 Cortwry Nvm u s M ID Number <br /> B.Designated Fac0i Name arta Sae Address US EPA ID Number <br /> Crean Esaroars 8ult`Ewrl err. LLC :=A u9$66p5 �� <br /> 253.; West Liter, Feed id'attanA 'we CA 3301 6 <br /> Fao',ri s Phone 561-?5:-6200 <br /> ga 9b U S-DOT Desrnpbcn(mciudinp Proper ShgWV Name Hazard pass,fD Number 1D Containers <br /> 11.Tuns 12,Urri <br /> Hkt and Pac"r g Group rd any)) No Type Quannty %M Ab13.Waste Codes <br /> 1 RCL NA2212.Ai bestos ? III [ERG 1711 IDUP022 0-11 <br /> a <br /> a 151 <br /> LU <br /> x 2 <br /> IL <br /> c7 <br /> 3 <br /> 14?,pkat Handing J.dIMCDoris and fion <br /> Ernergenclr Reipense Phine a 3-4MS Contact narre LLNL ErrlerQeftCv Ekspatch. Load No ETW 19-04.Ship Loc No 5-237024 <br /> REreraenC3 rdErasenurrber ars Irs�arce.Cc 3w: :. EIn nurr1irLVhF2-9Z.,. <br /> mode;to-Ca nos& 180.53 fl �! <br /> 15 GENERATOR'SIOfFEROR'S CERTIFICATION:I "dare that the camlerfs ofhs oc ns"ril are Ur and a=m*de=bW nova by the proper SNMng dame,and are dJassrhed,packaged <br /> marked and LVwW4W Carded and are in a)resp"m proper cwd*m ler trdnspoM acCra"to a.,V cable nWMhonal art nabOrW gp mrgirerrtal r-�s.If esport shpmml aid I ar-the Primary <br /> Eapartet i Cemdy aa1 ft niclents of the consignment wrdorm to Me terms of ft aaadted EFA Ackm Wedgmesri of Consent <br /> :cert:ty!liar the waste mrLmQat=sta!em t den.,ed in 30 CFR 262 27(a)(if i am a large QW", gcnerafor)or(b}(if l am a SrS181I 9 Imre. <br /> GeneratdrsCfferorsPrm:ediyptdNarne Spnature Mwo Day Ymr <br /> Scott A Drat arr t+r bef:f: tr NNSA <br /> F16 Intarnatortal Snquments <br /> y Import U S ❑Erpert from U S Pon otentry-sat: <br /> Twisom7er signature(for exports cmllr Dale I4avntg U S <br /> w 17 Tra:.sponer Acknowizdpwil of Rom pt d klatenA <br /> OTrac- 1 P Wined typed Name u)nalure Month ay Year <br /> CL <br /> QT+nsponer 2 prinlealTypea Name Sg2ture MorM pat, Yew <br /> tr <br /> 19 Dwepare y <br /> $2a DrscrMruy Ind=36on Space ❑Quant ry ❑Type ❑Residue Pammat Repaton ❑Fut Roo. <br /> ktarufeS <br /> 15a Aherna is Fawy jar Generator) Raserenca Nun-DarU S EPA ID Number <br /> U <br /> LL Fart y s 4li ore <br /> 16c.Srgna:ure Of AUTIM10 Facdmty kor Geretaw, Month a} Yew <br /> Cn19 Hazardous Waste Reporf klanagemenMethod Codes MeCodes¢.e..tndn(Orhazardorn waste freahlenl.disposal and recjdiN systema) <br /> p t 2 3 — <br /> Facility Camey or Operator Cerutmna,d recewt of hazardous materials covered=y ft.manifest .rs n h <br /> Ll Par, ,,Pd&. & Signature k <br /> o k I{o �� <br /> EPA a7 •�2;Rev 3 05) Previous ed Sans are obsolete IGNAT ED ACILEF 'TO 511 ATION STATE(IF RrElumED) <br />