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ihr °W1' ` `15 SYS1k hIS INC <br /> IJ S EI'A ID flurntder <br /> iransporlar 2 Company Namo I X R000"I iCQp`,i <br /> CLEAN HARBORS ENV SVC INC, US EPAIDflurnber <br /> Deslgnalod Facility Namo and SIIuAddross I MADO,i9 322250 <br /> CLEAN HARDtil S ARAGONITE I..I_C' US.EPAIDNumber <br /> 11600 NORTH APTIJfi ROAD <br /> Facility's Phone: <br /> 435-8134-0t&I ARAGONITE s LIT 840P.9 <br /> IJTD98I 3,,2177 <br /> nN <br /> oscriplien(Including Proper Shipping Name,Hazard Class,ID Number, <br /> up(if any)) 10.Conlalners 11.Total 1i Unci <br /> No, Typo Ouanlily <br /> 0NON RC"�A FIP.t_AC1DC)US bIASTE SOI_.IpS, <br /> BFN'1'S CINTAItIINATEU WII'Id OIL>,w <br /> 14.Special Handling Instructions a,,,-01lional Information <br /> TSD:A6 A 10 6 li.5% F1[)1`r!►c!q CSG <br /> ''4H EMER"NCY#'O'-4613-1760—CH/SK/TFI—Contract retairlted by generator confers agency author <br /> o ini+ia tra <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: hereby declare Thal the 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 in proper cendil on for Iransporl according to applicable international and national governmental regulations,If export 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 /> ce tify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quanlily generator)is true. <br /> GEOBrd101s/Off�ror's Prinled/Typed Name Signaturo <br /> on Day (ear <br /> w 16.International Shipments <br /> F ❑ <br /> Transporter signature(tor Import to U.S. ❑Export from U.S. Port of enlry/exit: <br /> ? exports only): <br /> Dale leaving U.S.: <br /> rY 17.Transporter Acknowledgment of Receipt of Materials <br /> w _ <br /> Transpo r 1 Phnted/Typed Name -- - <br /> 01 �./ir 1 Signalure <br /> a J / ^• Month Day Year <br /> z Transporter 2 Pr meatyped Name -� ` � �r"�' f ; H <br /> < Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El � <br /> Quantity ❑Type ❑Residue ❑Partial Rejection 1 ❑Full Rejection <br /> Manifest <br /> 180.Alternate Facility(or Generator) Reference Number: U.S.EPA ID Number <br /> J <br /> U <br /> LL- Facility's Phone: <br /> in 18c.Signalure ofAllemale Facility(or Generator) <br /> Q Month Day Year <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste Irealir 1,disposal,and recycling systems) <br /> LU <br /> � 1. <br /> ,4. <br /> 9 i <br /> 20.Designated Facility Owner or Operator:Certificalion 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 8700-22(Rev.12-17) Previous editions are obsolete. <br /> i)85GENERATOR'S INTI :,L COPY <br /> 33003/17802`•32 <br />