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zz-7?6,Ogg3 <br /> sty ��F�rp�� IIIIII111111loll I I I I <br /> � aa�9s= sasaKa <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number Z P ge jo1 3.Emee enc Res onss Phon 4."Manifest Number <br /> r,A100037:,509 1 ���-4,6-17�� 0 69528 5 SKS <br /> WASTE MANIFEST <br /> 5.Generator's Name and Mailing Address Generatods Site Address(if diNerent than mailing address) <br /> RLr €7h Rrlhher Co. .Inc. <br /> (?:R.--7r t Linne Rd <br /> T17,P17V CA 953014-9109 <br /> Generator's Phone: i= "3—$36--Co955 <br /> .- <br /> 6.Trans orter 1 Com any Name U.S.EPA ID Number .I,X RO11O1181 05' <br /> fFFT'+'--�`.!_FF.^d SYSTEMS ING <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLFP.N! 4 AIRT ORS EN4iIRON'MENJTAI_, SVC TNC. RIAf Q �:3i 5[Yt <br /> 3.Designated Facility Name and Site Address CLEAN HARBORS SAN _OSF U.S.EPA ID Number <br /> 1l RERRYEaSA R901' <br /> Facility's Phone. SAN J09F ;;^,A 351'" <br /> go 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 1f.Total 12.Unit <br /> HM and Packing Group{if any)) 13.Waste Codes <br /> No, Type QuantityWl.Noi. <br /> 1 <br /> 'Ill fa3tr512 HAZARDOUS WASTE ILIQUID, <br /> .J DM C' T)�t1 ��'3 <br /> or N i0. , (LFPM!, 9, PG <br /> a <br /> OfW <br /> 2 2, <br /> W <br /> C9 <br /> 3. <br /> 4. <br /> 14,Special Handling Instructions and Additional Information TPD 9J 790,R:;Q(-' R 1 5429 �,SS <br /> 1 F ai;1;171 f]� <br /> 4tn FREERrPJCY#$0@-468-1754 CH,SKfTFr-Ccantracf 'e aimed t1y tTerre�ator cnnfers a cy abttftGri y <br /> O t t. Q <br /> 15. GENERATOR'S10FFEROR'S CERTIPCATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplecarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and 1 am the Primary <br /> Exporter, certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent, <br /> I certify,that the waste minimization statement identified in 40 CFR 26227(a)(if I am a large quantity generator)or(h)(if I am a small quantity generator)is true. <br /> Generator'slCfferors Pnntecirryped Name Signature Month Day Year <br /> J 16.International Shipments <br /> h. ❑Import to U.S. ❑Expon from U.S. Portof entrylexit: <br /> Transporter signature(for exports only): Date leaving U.S.' <br /> W 17.TranspoderAcknowledgmentof Receiptot Materials <br /> W <br /> Transporter 1 PrintedlTyped Name <br /> Signature� 9 Month Day Year <br /> g 1-1 A NJ I-- All .� . - 107-117 1119 <br /> Z PrinName Signet Month Day Year { <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection 3 <br /> F 18b.Alternate Facility(or Generator) Manifest Reference Number: <br /> U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> 18c.Signature ol'Altemale Facility(or Generator) Month Day Year <br /> a ' <br /> z <br /> h19.Hazardous Waste Report Management Method Codas(Le,codes for hazardous waste treatment,disposal,and recycling systems) <br /> p 1. / 2. 3.�ez I — I <br /> q, <br /> 20.Designated Facility er or Operator Certification of receipt oL4Waidous materials cove the manifest except 449fied in It m 18 <br /> Pdntedi Name Signature Monts 0 ge <br /> EPA Form 8700-22(Rev.12-17)Previous editions are solete. <br /> 1)A7 7f!n 2)V i f 7p i DESIG EDF !CITY TO EPA's e-MANIFEST SYSTEM <br />