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Please print or type.(Form designed for use on elite(12-pitch)typewriter.)4B 1502395283-002 SC PPW 7/4/2015 Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4,tlU T/� u �} <br /> WASTE MANIFEST C A L 0 0 0 3 7 9 0 8 5 1 ;800)483-3718 `t 9t O 1 FLE <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Lathrop Oita of <br /> 2112 East Louise Avenue SAME <br /> Lathrop.CA 95330 <br /> Generator's Phone: (2)091941-7442 <br /> Transporter 1 Company Name U.S.EPA ID Number <br /> Glean Harbors Environmental Services Inc MAD 0 3 9 3 2 2 2 5 0 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Clean Harbors Buttonwiilow LLC <br /> 2500 West Lokem Road CAD 9 8 0 6 7 5 2 7 6 <br /> Btrttonwillow.CA 93206 <br /> Faality's Phone f66i1762-6200 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unii <br /> HM and Packing Group(if any)) No. Type Quantity WtN It 13.Waste Codes <br /> l. <br /> 1. NON RCRA HAZARDOUS WASTE SOLIDS,(FILTER CAKE 181 <br /> o SLUDGE) _- + <br /> z 2. i <br /> Lu <br /> 0 ) <br /> s <br /> I <br /> 3. { <br /> 4. <br /> r <br /> 14.Special Handling Instructions and AddibonaInformation <br /> 1_CIi5r35757B - <br /> 15. GEN ERATOR'SfOFFFROR'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 Intemational and national governmental regulations.If export shipment and I am Me Primary <br /> Exporter,I oI that the contents of this consignment conform to the terms of the attached EPAAdmowledgment of Consent. <br /> I certify that the waste minimizalion statement identified in 40 CFR 262.27(x)(if I am a large quantity generator)or(b)(if I am a small quantity generator)Is true. <br /> Generato sl erors Printed yp am mony Year <br /> 16.International S ments <br /> ❑Import to U.S. ❑Export from U.S. PSR of enl <br /> Z <br /> Transporter s' nature for exports only): <br /> Date leaving U.S.: <br /> w 17.Transporter Acknowledgment cf Receipt of Materials <br /> �T�ra�n r 1 PdntedfTyped Name Signature . Doth ay ear <br /> A _ IS <br /> Qnspo ter 2 PhhtedfTyped Name igneTure Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> Q <br /> ++ <br /> Facility's Phone: <br /> 18c.Signature of Altemate 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 /> LU 1 Hi32 2 3. T- <br /> 20 <br /> Designated Facility Owner or Ope,ator:Certifuabon of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed(fyped Name Signature Month Day Year <br /> r <br /> -Ii <br /> ..Z,,1!2 I �7-1-1—!:�-�� vz-py L <br /> EPA orm t3Z00 22(Re .3-05 Prev'ounate s editions are obsolete. DESIGNAYD FACILITY TO DESTINATION STATE(IF REQUIRED) <br /> Clean Harbors has tI1e approppermits for and will accept the waste the generator�s shipping. <br />