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<br /> ." or type. Form Approved.OMB No.205DM39
<br /> UNIFORM HAZARDOUS I.Generator ID Number 2.Page 1 of 3 Emergency Response Pharse �.Manifest Trackl Number
<br /> WASTE MANIFEST W89t�0U2 1 92S-A�,�Q� 419 4 45579 JJ K
<br /> 5.Generator's Name and Malsrtq Address Generators Site Address(if d4lerant than mailing address)
<br /> LBWrCttO�LhlQlirlOy B I I�Ofi4{Lob
<br /> 57t!'3!]O Of1 f of
<br /> t E lL'�} 7V5A U lME=re MffftrW LL'h ME 3D CA b~Of da 1111 WBA
<br /> P a Dx IM/cuss fie a M51 wnd HaMalldr R02d TMCY CA 933M
<br /> Generators Phone: 925-4V-1925 ATTN:
<br /> 6.Transporter 1 Company Name U.S.EPA ID Number
<br /> Clwn Harbors EnvironMental S0iv1= Im MA=93MM
<br /> 7.Transporter 2 Company Name U.S.EPA ID Number
<br /> —i r i Na�,, 4ot" 66 b-Do%-;;-OL 82 7
<br /> 8.Designated Facility Name and Site Address U.S.EPA Id Number
<br /> Cilmq hlairbw ftqcW,,z LLC 11=NWth AptM R -A AMWM UT 84M LRMISS2177
<br /> Facility's Phone;
<br /> 9a, 9b.U.S.DOT Description(ncluding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit
<br /> HM I and Packing Group(i any)] 13,Waste Codes
<br /> No Type Quantity Wt.Nd,
<br /> 1•IIN3379,Waft rJesmshized eWkdve,k0d,rLO.di.(ItMX,RM, DM 4a7 P DOM I FORS
<br /> 3,i WT-SP ISM){ERG M DOF'BDS*X-I 343
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<br /> 2. ►uni xS,w ,P01YdidWi,.-t, t , a,9,111{oUc Of DM w
<br /> sterVke Deat05ill7MM[ERE 1711 DoP0075-2 261
<br /> 3. RIL UN2315 bmte,POWhilobated ttolr ly s,Ugaid,9,19(out of
<br /> 30rrk6 We 03/IVM19)(ERG 1721 DOP0075-1 ?.Z1 261
<br /> a M UUM3Z Was#,PdVd*WI4KVd WM4%Ea1id,9,IN{OW of R
<br /> Sarvlca Data 0312*2118j{ERG 1711 DOM31-1 751 1261
<br /> 14.Special Handling Instructions and Additional Information
<br /> E"*WM Re4l0wll M5423-4�-ConW na 7 e rwi_EMME f►fir MVattk L02d V►t,P r UW6, D=Mm S-251172,
<br /> Item rdeM MMdw XE 01& on it1 . QOMM9=c lt-SS,Q00MOK 00GE3135$0
<br /> 15. GENERATOR'SIOFFER.OR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are dassified,packaged,
<br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable intemabonaland national governmental regulations.If export shipment and I am the Primary
<br /> Exporter,I certify Thal the contents of this consignment conform to the terms of the attached EPAAclmowledgment of Consent.
<br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(41 am a small quantity generator)is true.
<br /> GeneralorslOtferors Printed/Typed Name SgnatuT_-� Month Day Year
<br /> salt a C-48teM on WWI of the U.S.NNSA
<br /> 16.International Shipments
<br /> F ❑Import to U.S. ❑Export from U S. Port of entry-exit:
<br /> z Transporter signature(for exports only): Date leaving U.S.:
<br /> �
<br /> 17 TranspoderAeokowledgment of Receipt of Materials
<br /> Transport r t Pnnte&T),ped N70 t Signature ) Mach D/ay Year
<br /> a
<br /> Z 19
<br /> Transporter I PdriMff Name MISS
<br /> (1 A/� J/ GL Days, Year
<br /> 18.Discrepancy
<br /> 18a,Discrepancy Indication Space El Quantity ❑Type ❑Residue El Partial Re)eclion ❑Full Rejection
<br /> Manifest Reference Number.
<br /> 18b,Alternate Facility(or Generator) US EPA ID Number
<br /> U
<br /> ra+. Facilitys Phone:
<br /> W 180.Signature of Aftemate Facility(or Generatori Month Day Year'
<br /> a
<br /> z
<br /> 19.Hazardous Waste Report Management Method Codes(i,e.,codes for hazardous waste treatment,disposal,and recycling systems)
<br /> LL! 1 ?N D i k
<br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manliest except as nded in Item 1 Ba
<br /> PrmtedlTyped Name 4 t Signature Month Day Year
<br /> Ei'AForm 000 tev.12-M Previous editions are obsolete. DESIGNATED FACILMO GENERATOR
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