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a13L SK SH I <br />Please print or type. (Form design j for use on elite (t2 -pitch) typewriter.) <br />0 0 4 4 2 IIIIINNI1 1 5 7VIaAY <br />' $ K 3 <br />Form ADDroved. OMB No. 2050-0039 <br />EPA Form 8700-2 s editions 8M obsolete. <br />I <br />4 ) 7364AVMVTA1T Tu <br />DESIGNATED F-ArIL11TY TO DESTINATION STATE (IF Ra ED) <br />UNIFORM HAZARDOUS 1 1. <br />3 enerato, ID Number <br />12- Paget of <br />3.1me <br />f4 <br />arg esgr <br />rh <br />4. Manftd ng qNrw <br />0 4 423157 <br />SKS <br />WASTE MANIFESTCAL900366211 <br />5. Generator Name and Mailing A <br />Jdress Geneit dcss>s <br />ili, <br />09 0") <br />Firestone 028746 <br />720 E Hamper <br />Ln <br />- <br />CA 95,010-2736 SEP 15 <br />2015 <br />Generator's Phone: 209- <br />G <br />35 1 -2403 <br />6. Tir"r 1 Com <br />V <br />TY IT ETr <br />3YSTEM,9, INC. <br />U.S. EPA ID Number <br />FLILIMChIMELUL'TXR2,10008121015 <br />7. Transporter 2 pony Name <br />"PA ID Number <br />8. Designated Facility Name and S eAddress CLEAN HARBORS BUTTONWILLOW, Ll..0 <br />U.S. EPA ID Number <br />2500 LOKERN ROAD <br />I <br />BUTTONWILLOW CA 93206 <br />ff,'� I--7 <br />62--G200 <br />CAD981211675-52-16 <br />Facilh 's Phone: <br />9a. <br />9b. U.S. DOT Description (nchiding <br />Proper Shipping Name, Hazard Class, ID Number, <br />10. Contain <br />11. Total <br />12. unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (If any <br />Quantity <br />MN01. <br />1. NONE NON <br />ICRA HAZARDOITS, WASTE LIQUIDS <br />DM <br />P <br />.-:43 <br />(814AKE F-UTD), N/A <br />Z <br />2. <br />LLJ <br />3. <br />4. <br />14. Special Handling Instructions a <br />id Additional Information <br />TSD .BL 64725506 FT21-19 <br />P CSG <br />0" �0 3 -�Y <br />2 - HR EMERGENC <br />. 4 <br />' #1 -800-468-1760 (SAFETY--KLEEN) <br />SK GUMORIM <br />-U HEMIN I- LIMED SUB-5EQUENT MRRIERS-REA-1ESSaIRY <br />15, GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately des <br />ribed above by the proper shipping name, and are classified, packaged, <br />marked and labeled1placanlec <br />and are in all respects in proper condition for transport according to applicable international and natic <br />ug governmental regulations. If export shipment and I am the Primary <br />Exporter, I certify that the con i <br />nal of this consignment conform to the terms of the attached EPA AckwMedgment of Consent. <br />I certify that the waste minlimb <br />ation statement Identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (III am a smal quantity generator) Is true. <br />Ge '10". Prin yped <br />16. International Shipments <br />Pam Signattare <br />E. n import 1. U.S. part from U.S. Port of enti !exit: <br />❑ <br />Month Day Year <br />-j <br />I- <br />Transporter signature (for exports <br />wly): Date leavin <br />I U.S.: <br />w17. <br />Transporter AckraMedgmentof <br />iecelpt of Materials <br />Transpo Printed/Typed Na79 <br />Signature <br />Month Day <br />Year <br />NI; ,/-f 12 <br />Uif <br />TranWer 2 PrintedlTyped NNne <br />nature <br />Month Day Yder <br />18. Discrepancy <br />18a. Discrepancy Indication Space <br />0 Quantity F-1 Type ❑ Residue <br />Partial Rejection <br />F1 Full P.O. <br />Manifest Reference <br />I lumber: <br />18b. Alternate Facility (or Genersio <br />U.S. EPA ID Number <br />LL <br />Facility's Phone: <br />18c. Signature ofAltemate Facility ()r Generator) <br />Month Day Year <br />19 Hazardous to Report Manor l <br />lament Method Codes (i.e., codes for hazardous waste treatment disposal, and recycling systems) <br />U.1 <br />3. <br />4. <br />20. Designated Faci&*6 <br />A4 or 0 <br />enator; Certification of receipt of h ars materials covered by the manifest except as noted In Item f8a <br />Print <br />Mon r <br />EPA Form 8700-2 s editions 8M obsolete. <br />I <br />4 ) 7364AVMVTA1T Tu <br />DESIGNATED F-ArIL11TY TO DESTINATION STATE (IF Ra ED) <br />