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.t 2 7/2623504 Please orint or tvoe. (Form designed for use on elite (12 -pitch) tvpewritec) LIPSIC. 01194. 0427J SC PPW 10/29/2009 Form Approved. OMB No. 2050-0039 EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY THYDESTINATION STATE (IF REQUIRED) clean Harbors has the appropriate permits for 10655.1275thewaste theAenerator is shs pini. UNIFORM HAZARDOUS v 1. Generator ID Number CAL 0 0 0 1 6 7 7 3 2 2. Page I of 1 1 3. Emergency Response Phone (800) 424-9300 • 4. Mail t c n u be 6 2 7 0 MWI WASTE MANIFEST 5. Genera�toC� Nataeea Qd�tail"Ng d[ess_ Generals Site Address (f different than mailing address) IUllnit IE'rast• r2131rdd 1805 St 1.. 4520 Soutt, H:m 99 Frontage Rd Lithe Rock. AR 72206 3tackton.CA 95215 Generator's Phone: (501)376-7249 AM. Chris Baker: 6. Trans her 1 Company Name U.S. EPA ID Number Mean Harbors Environmental Services Inc IYi A D 0 3 9 3 2 2 2 0 7. Transporter 2 Company Name U.S. EPA ID Number aliffia f/ Q3ZZU-0 8. Designated Facility Name and Site Address U.S. EPA 10 Number Clean Harbors BtdtbrivAllow LLC .. CAD 9 8 0 6 7 5 2 7 6 2500.WestLokem Road Buttonwillow. CA 93206 . Facilitys Phone: (6611 762-6200. . ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Gass, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes No. Type HM and Packing Group (if any)) Quantity WLNoI. 1- _NONE. MON RCRA HAZARDOUS WASTE LIOUIDS. (SODIUM 13 a HYPOCHLORIM, N/A / /s"� z 2. . W c� 3 o, 4` 4. 14. Special Handlininstructions and Additional Information a L _CH38�2768 P".'r '7 15. GENERATOWSIOFFEROR'S CERTIFICATION: 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 oonform to the tarms of the attached EPAAcknowiedgment 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) (d I am a small quantity generator) is Vue. Generatoes(� es Name e Ski Month Day Year Ili r�ted/ryped J � 16. International Shipmen ❑ Import to U.S.LJ Export from U.S. of entry/exit = Transport* signature (for exports only): Date leaving U.S.: Lu 17. TransporterAcknowledgment of Receipt of Materials a Transporter edlryped Name Signatu Month Day Year f�J .fJA/ - / Transporter 2 Printed(Typed N Signature Mouth Day Year lX / �i vvt, IZ 12 101 18. Discrepancy 18a. Discrepancy Indication Space ®Quantity ❑ Type ❑ ResUue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number. 18b. Alternate Facility (or Generator) U.S. EPA ID Number _J V Facility's Phone: w i 8c. Signature of Alternate Facility (or Generator) Month Day Year 4 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) uJ I. H132 2. 3. a. 20. Designated Faduty owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a ffin yped Nama Signature Month Day Year //^^ tt -- EPA Form 8700-22 (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY THYDESTINATION STATE (IF REQUIRED) clean Harbors has the appropriate permits for 10655.1275thewaste theAenerator is shs pini.