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Please print or I pe (Form deigned for use on elite(12-pilrh)l dter,Pl 1300757254-002 SC PP W 1/4/2017 <br /> Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS I Generator ID Number 2.Paye 1 of 3 Emergency Response Phone A.V ' T i r <br /> WASTE MANIFEST CAR 0 0 0 2 2 2 5 6 2 1 ($00)483-3718 C� ��r�.4 5 5 FL E <br /> 5. 1'Or46Wj%Wmg Mdress Genomlor's$iter Address(d d&Mnl teen maling rddmss) <br /> 1000 Cobb Place Blvd NW Attn:Stere Clark 11950 Harlan Rd <br /> Kennesaw_GA 30144 Lathrop,CA 95330 <br /> Generator's phone, <br /> b. er 1 mpany amn an Qp4ca. <br /> �+� A /� ��(\\ U.S.EHA ID Number f'r �DL`-para <br /> *A ]'],._/j D0 u' ,�`,�1' +i_N _r.d 1 r1 rt rt r1 ra 2 2 Q c w <br /> T.Transporter 2 Company Name ((�,«11 '.I+C�1 lM1 U.S.EPA iD Number <br /> 8.Drsigrraled FariJily Nam,end Sile cess U.S.EPA ID Numhoc <br /> Clean Harbors Pecatoniea LLC <br /> 6125 North Pecatolnica Road 1 L D 9 8 0 5 0 2:4 4 <br /> Pecatonica,IL 61063 <br /> Facltit s Phone: ($001421-3290 <br /> 9a, 9b,U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Contalners 11.Total 12.Unit <br /> HM and Packing Group(f any)) No. Type Quantity VA Not. 73.Waste Codes <br /> t UN3099.WASTE OXIDIZING LIQUID,CORROSIVE,N.O,S., D001 D002 "If <br /> 0 x (SODIUM HYPOCHLORITE,SODIUM HYDROXIDEli.5.1.(8).PG a�75 C F 3 57 F7 <br /> 4 111 LIMITED OUANTITY &,07-- <br /> 2, ,0T-2. <br /> W <br /> cv <br /> 3. <br /> A <br /> 14,Speelai Harrclkv,)ImVwltcns and Addtllonal Im mnallon <br /> 1_ICA1232117 ERG#190 20750 CF ON d-7 PAI- <br /> 15. <br /> AL15. RENERATOR'SIDFFEROR'S CERTIFICATION 1 hereby declare that the contents of this conslgnmant am hilly and aaxuately described above by the pmWi,.hipping name,and are classified,packaged, <br /> marked and lobeledlplacarded,and are in all respects in proper oondlton for transport according to applicable International and national governmental regulatom.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of ire attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimizaton statement identified in 40 CFR 2f4221(a)(il I am a large quantity generalor)or(ti)(if I am a small qusrltty nnralor)Is true. <br /> nater sears (0110TYPed NW113 gna uny ear <br /> � 1b. ternatianal SMprnenls <br /> ❑import to U.S. ❑Export from U.S. Port of entry/exil- <br /> Tionsixr1q.r signature inn rls oml Date lea i U.S: <br /> Ge 17.Transporter Acknowledgment of Receipt of Materats <br /> Trannparlor 1 Pdnled/TName II u onLh 0 Year <br /> ,aL I 1 <br /> a <br /> Traaspurter 2 Prhrtedi7yprd Name y,r,r mortI <br /> r <br /> 18.Discrepancy <br /> 18a.Discrepancy Indicabon Space ❑ quantly ❑Type ❑Residue ❑Partial Rejection ❑Full Refection <br /> 181J.A Wrude Faed Mamfosl(defense ce Nwnher <br /> dY(or Generator) U.S.EPA r1 Number <br /> J <br /> U <br /> Q <br /> LL Fadli Phone: <br /> 23 18r:.Sigrnakre V ttornme FacRty(or Generator) Mordh Day Year <br /> a <br /> z <br /> N19.Hazardous Waste Report Management Method Codes(,a.,codes far hazardous waste treatment,disprrA,and recycling systems) <br /> 1. Hi4i 2. 3, 4. <br /> 2D Designated Fauility Groner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item i Be <br /> PrintocYTyped Narna p Slglmlunt Month Day ear <br /> 1 r� <br /> EPA Fa-n 14a 7 ( v�Fs a;r�rl� �PIL pf17iC perFn s for and will accept the waste the AenePMAYj 0ILITY TO DESTINATION STATE(IF REQUIRED) <br />