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SC PPW 10;i0/2017 s _4 U +t b r l <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) I w� 0 /�� Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST ICAL000359102 1 ($00)4$3-371$ 1 011583976 FLE <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> DTE Stockton LLC <br /> 2526 W.Washington Street 2526 W WashingTon Street <br /> Stockton.CA 85203 Stocktoill 95203 <br /> Generator's Phone:(2091320-3714 ATTNJesse Leywis <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Il At lCk4- • ' e. GA- O 5 3 <br /> 7.Transporter 2 Co ny Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA iD Number <br /> Clean Harbors Buttamritlow LLC CAD 8 9 0 6 7 5 2 7 6 <br /> 2500 WestLokem Road <br /> � OGG41 711013-1161300 <br /> llow.CA 93206 <br /> Fs <br /> R one: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.lVol. <br /> 1Z 1 Ulla 9,0ORROSIYESOLIDS.N.O.S.,(ARSENIC.CHROMIUK _ <br /> x S.PG III.(6OTTOM ASH] <br /> z 2. <br /> W i <br /> C7 -- <br /> 3. <br /> 4. <br /> s <br /> 14.Special Handling Instructions and Additional Information <br /> i.CIR1346380 ERG#154 <br /> 15. GENERATOR'S10FFEROR'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 Iabeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and t am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement idenfrfied in 40 CFR 26227(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> eneratorro rinted yName i na on ay Year <br /> s! er�s Pped 9 <br /> /f/M14v SM a? ure <br /> =j 16.International Shipm is ❑Import to U.S. ElExportfrom U.S. Poll ent exit: <br /> F— <br /> Z Transporter sinature for exports onl : Dale leaving U. : <br /> X 17.Transpo Acknowledgment of Receipt of Materials <br /> Frans r 1 'ntedlTyped N e ig o f ay ear <br /> oIll I7 <br /> U) <br /> Transporter rinledlT a -e ignature Month ay Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> a <br /> W <br /> Facility's Phone: <br /> 18e.Signature of Altemate Facility(or Generator)Ul <br /> Month Day Year <br /> a <br /> Z <br /> N19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> O 1' 2. 3. 4. <br /> Hi32 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in It 8a <br /> P cry ame Signature Month Day Year <br /> rf !?Tf <br /> EPA Fo 87 - 2(Rev.3 05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> clean Ftarbofs has the appropriate permits for and will accept the waste the,Xcnerator is shipping <br />