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<br /> Please print or type. Form Approved. OMB No. 2050-0039
<br /> UNIFORM HAZARDOUS 1 . Generator ID Number M , 2. Page 1 of 3, morgencyRogriss Plfone 4.1007313217 MManilesttTraaccking Number
<br /> WASTE MANIFEST ,. ll l� tiV� � lif/+tLl 'ta £� .- �11.
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<br /> 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address)
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<br /> SII Y(TON
<br /> Generator's Phone: ;P0+ 1 91e`1.' IFId07 '
<br /> 6: Tr�n'Bprorter Co p ny r U.S. EPA ID Number
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<br /> 7. Transporter 2 Company Name U.S. EPA ID Number
<br /> CLKAN HARBORS Ft ?� r) 4 INGO
<br /> 8. Designated facility Name and Site Address f,14 AN HARBORS SAN MARE U.S. EPA ID Number
<br /> 1021 BERRYESBA ROAD
<br /> SAN 1,'t_firES 5 CA 95133
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<br /> Facility's Phone:
<br /> 9a 9b, U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11, Total 12, Unit
<br /> HM and Packing Group (if any)) 13. Waste Codes
<br /> No. . Type Quantity WI.Nol,
<br /> 1 NON - IRGRA HAZARDOUS WASTE 0L. SDS #:1 21
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<br /> 14, Special Handling Instructions and Additional Information Lf &1 8 14 1, lC1 ya A14, 4 4) 11'7 i.
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<br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that INe'contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged,
<br /> marked and labeled/placarded, and are in all respects inproper, condition for transport according to applicable international and national governmental regulations. If axport shipment and I am the Primary
<br /> Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent
<br /> I certify that the waste minimization statement Ideriliged In 40 CFR 262,27(a) (If I am a large quantity generator) or (b) (III am a small quantity generator) Is true.
<br /> Generator's/Offeroes Prinledfryped Name Signature .. . : t Month Day Year
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<br /> 16. International Shipments ! r 7
<br /> ❑ Import to U,S. 0 Export from U.S. Port of entry/exit
<br /> trans oder si nature (for ex ors only):
<br /> - Date leaving U.S.: .
<br /> W 17. TransponerAcknowledgment of Receipt of Materials
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<br /> Transpgrier 1 Printed3pisd Name Signatufe' - Month Day Year
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<br /> nledfTypedName Signature ( f Month Day Yeali
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<br /> 18. Discrepancy
<br /> 18a, Discrepancy Indication Space F Quantity ❑ Type ❑ Residue ❑ Partial Rejection . Full Refection
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<br /> Manifest Reference Number
<br /> 18b..Allarnate-Facility. (or Generator)
<br /> U.S. EP_ A ID Number:
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<br /> ua. Faclllly's Phone:
<br /> W 18c. Signature of Alternate Facility (or Generator) [Moon571hDay Year
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<br /> N19, Hazardous Waste Report Management Method Codes (i.a,, codes for hazardous waste treatment, disposal, and recycling systems) ;
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<br /> 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a
<br /> Printed/Typed Name Signature „ Month Day Year
<br /> EPA Form 8700-22Rev. 12-17) Previous editions are obsolete. GENERATOR' S INITIAL COPY
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