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boa i1 3el <br />0 <br />Please prig gator acknowledges that no matenat change has occurred either In the characteds ics or In the process generAIngF ft qSVq&. OMB No. 2050039 <br />EPA Form 13706-22 (Rev. 12-17) Preus editions are obsolete. UtWUNA I W rAtAL1 i T I V arm s e-mnmrrw r o r,) r Gm <br />Clean Harbors has the apmpriale permilts for acid It M accept the waste the generator Is shipping. WSC 20012835294M PPW <br />UNIFORM HAZARDOUS 1. Generator ID Number <br />2. Page 1 of <br />3. EmResponse Phone RespoPhone <br />4. Manfilest Trracking Nummber <br />014788827 F L E <br />WASTE MANIFEST <br />5. Generator's Name and Mailing Address Generalor's SitoAddress (ff different than mailing address) <br />St ckwn Delta Resorb LLD <br />14900 W HigFWM 12 SAME <br />aC�242 <br />6. Transporter 1 Company U.S. EPA ID Number <br />7. Transporter 2 Company Name U.S. EPA ID Number <br />8. Designated Facility Name and Site Address U.S. EPA ID Number <br />Clean Harbors San lose LLC CAD 0 5 9 4 9 4 31 O <br />1�0n21 Bw messa Road <br />FRIP, fj s Aurone': • CA 951 3 <br />9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, Irl Number, 10. Containers 11. Tohal 12. Unit 13. Waste Codes <br />HM and Packing Group (if any)) No. Type Quantity Wt.Nol. <br />1. <br />M203, WASTE GASOLINE. 3. PG 11 <br />DOW <br />11011 A <br />9-13 <br />11 <br />x <br />T" <br />eoa <br />P <br />Z <br />2. <br />W <br />C7 <br />3. <br />4. <br />14. Special Handling Instructions and Additional Information <br />1 -Cf l.965359 E=#12a <br />IContfact retained by Generator conkre ager <br />211511 <br />15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that The contents of this consignment are fully and aocuratety dawn above proper s ung name, a arecrRaw- <br />marked and labeledlplacarded, and are in all respells in proper condition for transport according to applicable intemationaland national govemmental regulations, ti export shipment and I am the Primary <br />Exporter, I m* thatthe contents of this consignment conform to the terns of the attached EPAAdu wIedgment of Consert. <br />I certify that the waste minimization staternent identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (dI am a small quantity generator) is true. <br />Moro <br />e. 19 20 Year <br />j <br />16. International Shiprnenls ❑U.S.� to UExport from U.S. Pat of enkyfexit: <br />K <br />Transporter signature (for exports only): Date leaving U.S.: <br />W <br />LU <br />17. Transporter Admowledgmeat of Receipt of Materials <br />Transporter 1 PnnWFyped Name Signabxe Monlh Day Year <br />aiUr <br />L/ ., r 3 1ZD <br />Z <br />Trargxxter 2 Prinledlryped Name SignatureMonth Day Year <br />H <br />18. Discrepancy <br />18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejection ❑Fug Rejection <br />Manifest Reference Number. <br />18b Alternate Facey (or Generator) U.S. EPA ID Number <br />J_ <br />V <br />w <br />Facility's Phone: <br />Uj <br />18c. Signature of Alternate Facility (or Generates) Month Day Year <br />a <br />z <br />H19. <br />Hazardous waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />LU <br />1. 2. 3. <br />4. <br />H141 <br />20. Designated Facility Owner lir Operator pt of hazardous matet mate'covered by the manifest except as rKted in Item 18a <br />Na � Y <br />nunr�u <br />EPA Form 13706-22 (Rev. 12-17) Preus editions are obsolete. UtWUNA I W rAtAL1 i T I V arm s e-mnmrrw r o r,) r Gm <br />Clean Harbors has the apmpriale permilts for acid It M accept the waste the generator Is shipping. WSC 20012835294M PPW <br />