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Please print or type. (Form designed for use on elite 12-pitch) typewriter'. Form Approved. OMB No. 2050-0039. <br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page i of Emer ency Response Phone 4. Manifestt TTrackingg Number (� Q �[ cWASTE MANIFEST CAC,- 00 © / 1J 3 � ( � 1 .3. <br /> � -��-46q- 17�d O 0 L 2 V � � � W SKS <br /> 5, Generator's Name and Mailing Address Generator's Site Address' (if diffeteht than mailing address) <br /> JA <br /> /Z lJ4 1) 0492 <br /> T <br /> Generator's Phone: ,,. , jI.N5 All / <br /> 6, Transporter. 1 CoMpah ,la e " �/ U.S. EPA ID Number <br /> t- P! SYSTEMS INC <br /> _ ! - - <br /> 7. Transporter 2 Company 'Name'`.. • - U. S. EPA ID Number <br /> CLEAN HARBORS ENVIRONMENT LI SVC INC . MAD939322258 <br /> 8, Designated Facility Name and Site AddressCLEAN HARBORS OF: W I LN I NGT LN LLC U.S. EPA ID Number <br /> 1737 EAST DENNI STREET <br /> WILMINGTON CA 90744 <br /> y 1 �► H 5 -9998 <br /> Facility's Phone: CAD044 4298,35 <br /> ga 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)) No. Type Quantity WLIVol. 13. Waste Codes <br /> 1 NON- RGRA HAZARDOUS WASTE , SOLID 0M D Q ) 1 t' t' s <br /> o ( OIL F= ILTERS ) <br /> ru <br /> Z 2. � � a <br /> 3. MAR 2 8 2019 <br /> I <br /> i I <br /> ENVIRONMENTAL HEALTH <br /> DE. ART . , tT <br /> i <br /> 14. Special Handling Instructions and Additional Information <br /> JL I ' <br /> HR EMER6ENCY # i C�00- 4t=: �i - 1. 7SQ� ( SK i TFT ) 1J <br /> , i 1 f - c' ° ph : r� r. - - „ „ � , - 1 1 - <br /> 15, GENERATOR'SIOFFEROR'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, <br /> marked and labeled/placarded, and are in all respects in proper condition for transport according to applicab)e.intemetionatand, national governmental regulations. If export shipment and I am the Primary <br /> Exporter, I cert! that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> certify that thea Waste minimization statement idliaoif f in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am mall quantity genera or) isa, <br /> GeneratorslOffero`r's Printedffyped Name Signature i ` Month jDay Year <br /> J 16. International ShipnZnls ' <br /> i— ❑ Import to U.S. ❑ Export from U.S. Port of entrylexit: <br /> z Transporter signature (for exports only): Date leaving U.S.: <br /> w17. Transporter Acknowledgment of Receipt of Materials <br /> E2 Transporter 1 PrintedlTyped Name 71gE re Month Day Year <br /> Z <br /> Transporter 2 Printed/Typed Name / Signature n , Day Year <br /> 18.Discrep cy — <br /> 18a. Discrepancy Indication Space ❑ Quantity El Type ❑ Residue El Partial Rejection . - — El Full Rejection <br /> Manifest Reference Number: <br /> 18b, Alternate Facility (or Generator) U.S. EPA ID Number <br /> V <br /> LL Facility's Phone: <br /> w 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> a <br /> Z <br /> 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, -and recycling systems) <br /> ® 1 2. 3• 4. <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 FSignature Month Day Year <br /> rr <br /> EPA Form 8700-22 (Rev. 3:05) Previous editions are obsole . DESIGNATED FACILITYTO GENERATOR <br /> 0761R003 / 19(s 777 1 <br />