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<br /> Please print or type,(Form designed for use on elite(12 pitch)tyuerttiter.) ,�,2 /,'/f g •�'f��p� }� � �Form Approved OMB No.20'30.0039
<br /> T UNIFORM HAZARDOUS 1.Genatator ID Plun bar r;� r r ,+ ( y �.Pae 1 of 3 Em r etgc o �ggnse PJ enc 4. ant as Trackht Nuummba (�
<br /> WASTE MANIFEST 11.41Ltf ( r r etr I 1 c1 }i ! ,.',1 (� 5 y;J 7 ,3 S K
<br /> b.Generator s.Namo and Mailing Address Geherator's Site Address(it different than mailing address)
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<br /> Goner aloes Phone.
<br /> fi.T a sal [te,1 Co_ agy (a re r z U,S.EPA ID Number
<br /> `�{'t--T��..t�•>.;�`� sys,rHr'f; l c y [ i;tR000i'm}a),
<br /> 7.Transporter 2 Company Name U.S.EPA 10 Number
<br /> 8,Designated Facility Name and SiteAddress CLEAN HARBORS SAS� OSE U.S,EPA Ip Number
<br /> Cel 9!517n
<br /> QA )'.-2)-9 4 3 ilia
<br /> Faciiih's Phone: _
<br /> go. 9b.U.S.DOT Descripiioh(including Proper ShlpploName,Hazard Ciass;lD Number, 10;Container 11.Total 12;Unit' 13,Wasto Codes
<br /> HM and Packing Group,tf any)) No. Type Quantity Wl VOL
<br /> r it fill td tf Wit} i•fAZAR CUS 11408T-E EVA 1111"
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<br /> 14,Special Handling Instructions and Additional informationTBD;3y "t-7a7,11:3
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<br /> �lf..TF( AS r i' a(, 'fl r' - f=� 1 E S-}0 s, i CA OR 1 PS fit MIF
<br /> 15. GENSRATOR'SIOFFEROR'S CERTIFICATION:11 her,by declare that the contents ofINs consignment ara fully and accurately described above by the proper shipping name,and are classified,packagedi
<br /> marked and labeled!placarded;and are in all respects i i proper condition for transport according to applicable International and national governmental regulations.If export shipment and,l am the Primary
<br /> Exporter,I certify t}fatlhacontents of this consignment onform to thelerm's of the attached.EPAAcknowiedgmentof Consent
<br /> O�t erlity Wit a waste ointmfzatlon statement}dehtifie 1h 40 CF 262,27(a)(it l am a large quantity gamugjotyor(b)(ffl am a$Mo1(goanti erroralor)i Ince;
<br /> Genu o s/Otferors Prinlad/T Qed•Nem M nt Day f Year
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<br /> -.r 16.iniemational Shipments in Y f ;`
<br /> F- El Irnport for ,$. ❑Export from U.S. Port Ofenlrylexih
<br /> Transporter signature((or exports only): Palo I'aving U•S.:
<br /> 17.TransporterAcknowledgnlent of Receipt of Materials; ,.
<br /> Transp . PrinledlTyped Name ,r / Signatu r ,r Month Day Year.
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<br /> Z Transporter 2 Printedflgped Marne Signature Month Day Year
<br />` 18,Discrepancy
<br /> t 18a.Discrepancy Indication Space ❑Residue ❑Full Re
<br /> Quantity! ❑Type �ParU,l Rejection (eetion:
<br /> Manifest Reference Number:
<br /> 18b.Alternate Facility(or Generator) U.S,EPA ID Number
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<br /> Facilil j s Phone:
<br /> w 180.Signature ofAitemate Facility(or Generator) M0691 ( Day I `(ear
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<br /> 0 19.Hazardous Itlaste Report Management Method Codes(i. .,codes for hazardous wasto treatment,disposal,and recycling systems)
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<br /> 20.Designated Facility Owner or Opera o%Cedilibalion ofrei eipt of hazardous materials covered by the manifest except as noted in Item 18a .
<br /> Prints/Typed Name ` Signature f / Month Day Year
<br /> EPgqFgrm.9 0 2_(fj���3�5);P�reviousetlihonsareobsolee � 1 :)568 -1GWA-T5bFAGfiLITYTO GENEHATOR
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