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or type. Form Approved.OMB No.2050-0039 'UNIFORM HAZARDOUS I.Generator ID Number 2,Page 1 of 3 Emergency Response Phone 4.Manifest Tracld Number WASTE MANIFEST �28 QQx 1 9Z5-A�, Q� 419 4 5 5 7 9 JJ K 5.Generator's Name and Malsrtq Address Generators Site Address(if d4lerant than mailing address) LBWrCttO�LhlQlirlOy B I I�Ofi4{Lob 57t!'3!]O Of1 f of t E lL'�} 7V5A U lME=re MffftrW LL'h ME 3D CA b~Of da 1111 WBA P a Dx IM/OW fta a M51 wnd HaMalldr R02d TMCY CA 933M Generators Phone: 925-4V-1925 ATTN:Slag 6.Transporter 1 Company Name U.S.EPA ID Number Clwn Harbors EnvironMental-%0iv1= Im MA=932Z250 7.Transporter 2 Company Name U.S.EPA ID Number _k_ f 44-14zi), 66 Mb OL 82 7 R 8.Designated Facility Name and Site Address U.S.EPA Id umber Cilmq hlairbw ftqcW,,z LLC 11=NWth AptM R -A AMWM UT 84M LR ISS2177 Facility's Phone; 9a, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(i any)] 13,Waste Codes No Type Quantity Wt.Nd, 1•UN3379,Waft rJ SMSKizEd eWkdve,k0d,rLO.s.(ItMX,RM, DM w P DOM iFW5 3,i WT-SP ISM){ERG M DOF'BDS*X-I 343 LU 2. ►uni xS,w ,Patid*wI,.-t,~d a,9,111{ouc of DM 3m S DM 05/17/20M[ERG 1711 DOM75-1 261 3. R4 tJN2315 Wmte, ' liloftate'.d tIo1r lybf ,I quK 9,19(out of -%DrvkO We 03/IVM19)(ERG 1721 DOP0075-1 ?.Z1 261 4. M Ufj3MWets#,P rftvWW WM4%sa#d,9,IIi;OUt of X S nkD Arta 0312 MM{ERG 1711 DOM31-1 751 261 14.Special Handling Instructions and Additional Iniormatlon E"*WM Re4l0wll M5423-4�-ConW nart;,e rwi_EMME f►fir MsMttk L02d V►t,P r UW6, D=Nix S-251172, 15. GENERATOR'SIOFFER.OR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accuratety described above by the proper shipping name,and are classified,packaged, 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 Exporter,I certify Thal the contents of this consignment conform to the terms of the attached EPAAftowledgment of Consent. 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. Generalors101ferors Printed/Typed Name SignatuT_-� Month Day Year salt a GrateM on WWI of the U.S.NNSA 16.International Shipments F ❑Import to U.S. ❑Export from U S. Port of entrylexit: z Transporter signature(for exports only): Date leaving U.S.: � 17 TransporterArknowledgment of Receipt of Materials Transport r t PnnIL-&Typed Na eD t Signature ) Mordh Day Year 19 Z Transporter I PdnWa- Name S: AI � --- 0 Ai J/ GL Days, Year 18.Discrepancy 18a,Discrepancy Indication Space El Quantity El Type ❑Residue El Partial Rejection ❑Full Rejection Manifest Reference Number. 18b,Alternate Facility(or Generator) US EPA ID Number U Lit Facilitys Phone: W 18e.Signature of Aftemale Facility(or Generatori Month Day Year, a z 19.Hazardous Waste Report Management Method Codes(i,e.,codes for hazardous waste treatment,disposal,and recycling systems) LL! 1 � ?� 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manliest except as nded in Item 1 Ba PrintedlTyped Name 4 t Signature Month Day Year Ei'AForm 8 00'2 (Rev.12.1 Previous editions are obsolete. DESIGNATED FACILMO GENERATOR