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, SK SHIP# 229584202 ` Please�print or type. Form Approved:.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page I of 3.Eme ency Re nse Phong, Mani : 7 fast Tracking Number WASTE MANIFEST "W931 SKS 5.Generator's Name and Mailing Address V1 c Generators Site Address(if different than mailing address) TWV,Y CA 95304--9109 Generator's Phone: 6.Transporter I Company,Name U.S.EPA IDNu bar 7.Transporter 2 Company Name CLEAN' 4ARPARS, ENV SVC INC� U.S.EPA ID Number 8.Designated Facility Name and Site Address CLEAN HARBORS AMBONITU'l LLC U.S.EPA ID Number 6010 NOR'ni AiPTUS ROAD 9a. 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Contaii ers HM and Packing Group(if any)) Total 12.Unit lk No. Type Quantity Wt.Nol. 13.Waste Codes NON PURA HPZARDIMS, WASTE SOLIDS, IM LLJ 3. 4. 14.Special Handling Instructions and Additionalln—formaflon CSG 2-n iPitia tray= t 15. GENERATOR'S/OFFEROR'S CERTIFIC ION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. I certify 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 quantity generator)is true. GROQCaUb/Offefor's Printed/Typed Name Signature Month D 16.International thi�menrs 11 0 Import to U.S. Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: W 17,Transporter Acknowledgment of Receipt of Materials LU Transporter 1 Printed/Tyged Name, Signature Month Day Year Signature Month Day Ne—ar 18.Discrepancy 18a.Discrepancy Indication Space Quantity Type Residue Partial Rejection Full Rejection 18b.Alternate Facility(or Generator) Manifest Reference Number: U.S.EPA ID Number Facility',,Phone: 3 18c.Signature of Alter U nate Facility(or Generator) Month Day Year 55 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) LLI 1. Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a ame Signature —MOW Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. I I I I 1)85,38003/1780298 GENERATOR'S INITIAL COPY