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Please print or Type., r: Form Approved,OMB No.2050-0039 <br /> UNIFORM H42ARD601 Generator ID Number 2.Page 1 of 3. me R s e'11 4.Manifest Tracckiing Number <br /> 1111ASTE M' IFEST CAL GGO346876 1 "^ — 1 l sf� C' S KS <br /> 5.Gene is Name and Mallin Apress Generator's Site Atldress(if different than mailingaddress) <br /> A SA .= Gnl en Gate. ADESA d Golden Gae <br /> 18 01.West Stanford d Attn Saeuel..Mchenry 110501 Stamford Rd <br /> TRACY CA 95377 Attn Lester Sabo <br /> Generator's Phone: . 2 14-b, 374 I TRACY CA 95377-97138 <br /> 6.Tr0' , 0Y TE 9 INC,, U.S.EPA ID Number TXR012112108124115 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENVIRONMENTAL SVC INC. MAt?10139322250 <br /> 8.Designated Facility Name and Site Address CLEAN6iARDORS OF. BUTTONW I LLOW U.S.EPA ID Number <br /> r SSG LOKERN ROAD <br /> y BUTTONWILLCW s CA 93206 <br /> CAD980675V& �. . <br /> Facility's Phone:. <br /> 9a. 9b.U.S.DOT Deacripfon(including'roper Shipping Name;Hazard Class,ID Number; 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM; and Pecking Group.(it any)) 1 <br /> No. Type Quantity Wt.Nol. <br /> 1. NOH RGRA HAZARDOUS WASTE SOLIDS (NON DM P 3 <br /> o RCRA HAZARDOUS" WASTE SOLID (ADSbRDGNT ( � <br /> AND OIL)) <br /> Z 2 <br /> LU <br /> 3. <br /> 4. <br /> 14.Special,Handling Instructions and Additional Information 813E 7DRE+'- 511 'AD2S 198 s ' <br /> 0�; <br /> 241 GRSENQY 19 46D-°176G-CH/SK/TEI-Contract retained by generator confers agency authority <br /> on initial trans erter to.add or substitute additional transporters on eneratorgs behalf.. ' <br /> 15./GENERATOR'S/OFFEROR'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 applicable International and national governmental regulations.If export shipment and i am the Primary <br /> Exporter;I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Conset: <br /> ' I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b) if I a a small quantity generator)is true._ <br /> Gen6rator's/Offeror <br /> sPinted[Typed Name Xnre Month rDay <br /> , <br /> IV <br /> 16.International Shipments <br /> F El Import to U.S. ❑Export from U. Port of entry/exit:. <br /> 2 Transporter signature(for exports only): Date leaving U.S.: <br /> rY 17.Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> Transporter 1 Printed/Typed Name Signature Month DaYear <br /> Transpo r 2 Printedlfyped Name Signal t Month Day year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space El Quantity Type ❑Residue i. Paral Rejection ❑F�ui <br /> l Rejection <br /> Manifest Reference Number: <br /> .18b.Alternate Facility(or Generator)" U.S.EPA ID Number <br /> U <br /> Facility's Phone: <br /> W .18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 19,Hazardous_YVaste Report ManagemenGMethod Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> J L 12. <br /> ]3. 4. <br /> 20.Designated Facility 0 ' r Operator:Certification of receipt of hoz dous materials cevered by the manifest except as noted in Item 18a, <br /> Printed/Typed Name <br />€ EPA Ig, JR P v'ous editions obsolete. ' <br /> DESIGNATED FACILITY TO GENERATOR <br />