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S <br /> RECEIVED <br /> Please print or tylpe WLW19a Form Approved,OM9 No.2050-0039 <br /> UNIFORM MANIFESTS 1 GrerAera�QlD�Numl>er� (r6 <br /> Pag 10l3�.EmeZ esp�Phone a' nyc32JJK <br /> WASTE MANIFEST 1.J1 0U 19 R/}!� U <br /> 5.Gen a an nd Mailing Ad Lab�3W an of us PAW S Site Add d lift ) <br /> Ummm X aft of US XNSA <br /> PAL B=SM/L-7W Uvenr om CA 9+4551 hind Naft t Road.Tnw CA 9537!<i <br /> Generator's Phone: -LWS aTFIt ShWoke <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Clmn Harbors Environnulntal Serritas Inc. MAD03932UM <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> 6.Designated Facility Name and She Address U.S.EPA 10 Number <br /> Omn Sa brddla of stye Jaw,LLC=1 Besrymm Ro2d sea Jane CA 9S 33 CAD0594MIO <br /> Farah s Phone: 451-M <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10 Containers 11 Total 12 Unit 13.Waste Codes <br /> HM and Packing Group(d any)) No. Type Quantity WUVal <br /> X1 UN1993,Waste,Rarr nWWO ids.n. ..3,O(Lcb pet)EERG 1 DF i7s P 01 D035 <br /> 331 <br /> 2. UN1993,Waste,F�€ cis,rLo-%3,If Pb pad)[ERG �, JM W35 <br /> UM MWOM4 X1 I <br /> 3. UN1M Waste,G290Rne4 3,H[EW IA DOPOOS4.1 1 DM 43 -AJUi <br /> a RMME:lank contisinod UN1494 Sod#arn nkrase,5.2,in[EW I DF 25 <br /> 1401 DDPUW&1 <br /> 14.Special Handling instructions and Additional Inforrnatlan <br /> H Y M Phone 9 Corfu r>; m UAL Emerfm-try dr.Load 4 SI20-19,SI MP Doc fro-Sr•2'-�' <br /> Aelleronci>M E�� on Irr+dim Soo attathod far cand nor manbom <br /> Sy BCD -�RtO r-5e W&Y, 01 ode 95 5 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are hilly and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are lm all respects In proper condition for transport according to applicable kntematlonaland national governmental regulations.tf export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conIbr m to Ile terms of the attached EPAAcknowledgment of ConsenL <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(il I am a large quantity generator)or(b)(if I am a small quantity generator)Is true, <br /> Generator s<Dreror s PrinledlTyped Name Signature Month Day Year <br /> Scot A.Graham on bMvdf of US PIWA Z ao <br /> j 16.international Shipments <br /> ❑Import to U.S. ❑Export from U S. Port of emfrylexil: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17 TransporferAdpowledgment of Receiptot Materials <br /> Transporier1 P'tedff ame _ Signatu onth Day Year <br /> sporter 2 Prin-Wayped Name nature -` r Month Day Year <br /> 18.Discrepancy O <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Re*91 ::1 Fuld Re)eclian <br /> Mantes[Reference Number. <br /> 18b.Alternate Fadlkty;or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> U- Facility s Phone: <br /> W 18c.Signature of Aktemate Facility(or Generator) Month Dey Year <br /> a <br /> z <br /> y19 Hazardous Waste Report Management Method Codes(i,e.,codes for hazardous waste treatment,disposal and recycling systems) <br /> LU <br /> 2. h// <br /> / 3. /. 4. <br /> 20.Desgnated Facility Owner or Operator.Certifrcatlon of receipt of hapdous materials covered by the manifest except as nded in I 1 ' <br /> PriniedfTyped Name Signatu Man D Year <br /> EFrA Farm 8700-22(Rev.12-17) Previous editions are o sale'!. ESIGNATED L=ACILITYTO GENERATOR <br />