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BEC:"j,r✓''y'r*'1a . Please print or type. FormAWoved.OMB No,2050-0039 UNIFORM HAZARDOUS 1 Generator ID Number 2,Page 1 ai 3.Emergency Response Phone 4.Man[,°sTrid�NT Q(� JJ K WASTE MANIFEST 0194 Q o 5.Generators Name and Mailing Address Generatced Site Address(if different than malting address) Lffwmnm UvCfT[wM WU01U1 LA Sft WO=6eW of the uS.NftraA Lawrom L[vnotrQ ItdCrIIs Lft S!W 3M CM b&1 w Cr t1M1 U.S.WaA P.O.B=soft/WN UWrtr=CA 94u91 Carm hok w Raab,Trilmy CA Sion Generators Phone: 96-422-M ATM 6.Transporter,Company Name U.S.EPA ID Number Clean Harbors Envifunmer+tM: vRrc> Im 0 7 Transporter 2 Company Name U.S.EPA ID Number S.Designated Facility Name and Site Address U-S.EPA ID Number CIMa HWb=lAlftU00 1,L ILC 1737 E Derui Sr„eet,W R"W"CA W7'44 CAD04409835 Facd 's Phone: 9a 9b.U.S.DOT Description{including Proper Shipping Name,Hazard Class,ID Number 10.Containers 11.Total 12.Unit 13.Waste Codes HIM and Packing Group{d any}) No. Type quantity Wl Not. 1 WFACM hvMdM WMIte,140 0AED 011)IOPQIIS M DM -W- P 221 2 No*RMhazardous waft Hgwd(uSED olij DDpttaU-1 S DF 2u 221 3. Nasr-RCM hatarldous Wast%IWd1(UMD 09Lj AD 00po •1 DF 41 P 221 4 Nor>t-RCRA hazardous Vd=e,tigWd JWD CKQ DOP0080-1 DM 20M .221 14.Special Handling instructions and Additional Information EnKrZOM ReVorm Phom,925423.4M CmMict rlamiQ i -ML IErnergtxr Dispa Ch.Load 9'LAItUO-P2,Ship Ir No.s-251097. SW fished for Con rlwibm 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classed padseged marked and Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations If export shipment and,am the Primary Exporter,I certify that the contents of this consignment conform to the tarns of the attached EPAAcknowledgment of Consent. I certify that the waste minimization statement Identified in 40 CFR 262.27(a)(41 am a large quantity generator)or(b){ifl am a small quantity generator)Is true. Generators70Bemes Printed/Typed Name Signature Month Day Year Batt A.Grahams an beha f of the U&NMA I r Z !QI I,4 16 Intemabonal Shipments ❑Import to U.S ❑Expos from U S. Port of enlrylexit: Transporter signature(for exports only): =fi Dale leaving U.S.: w 17.Transporter AclumAedgment of Receipt of Materials Transporter HR 1 PrintecITYpelaffmr { Signature, Month' Day� year / C UZ 1. IL � Transporter 2 Pnnded yped Name Signature Month Day Year N- 16.Discrepancy lea.Discrepancy Indication Space ❑ Quantity ❑T ❑Ressdue ype ❑Partial Rejection ElFullRejection Mandest Reference Number. 1f,Altemate Facility(or Generators U.S EPA ID Number J_ L? uu- Facility's Phone tnu ,0c.Signature of A temate Facility,or erator) Month Day Year N19.Hazardous Waste Report Management Method Codes(.e.,codes for hazardous waste treatment,disposal,and mcyding systems) L� LLJ 1. 2. --T' qlq 20.Designated Facility Owner or Operator Certiircation of receipt of hazardous materials covered by the manifest excepttas noted in Item lea rim Name Signature Uointh Dq Year EPA Form 870D-22(Rev.12-17) Previous editions are obsolete. � � QESIGNAT�ICILITY lQ GFNERAT?f