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► i., t <br /> P -14 <br /> lease print or type.(Form designed for use on elite(12-pitch)typewriter.) 631894833 AFP:C110100 1.07DT19.2 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 c 7 1 0 0 0 2 3 2 1 8 1 3 (BOO)483-31 1 0 010 915 6 7 • FL E <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) ' <br /> Targc4 Store T-9313 <br /> 4707 Pzcft Ave <br /> Stachm,CA 93207 <br /> Generator's Phone: 209 47"081 ATDJ:Revcrs> Lo •fsJca?r li <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> Clean Harbors Bwiron"ntal Services Inc M A D 0 3 9 3 2 2 2 5 0 <br /> 7-Transporter 2 Compa y Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> Clean'Har ors La Pore L�D <br /> 500 @osCegrourrd Road T A D 9 8 2 2 9 0 1 4 0 <br /> La Porte,TA 77571 <br /> Faclity's Phone: 1`281111 727-78m, <br /> ga 9b.U S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number; 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity WtNol. 13.Waste Codes <br /> 1UN1978,1PJASTE PROPANE2.IPOINE DOW 343 <br /> X 002 C 3 0002 P <br /> OUT 80i14 <br /> z 2. <br /> w <br /> C7 <br /> 3. <br /> 4 <br /> 14.Special Handling Instructions and Additional Information <br /> 1. LC i'1 LP 2XC YLE ( 1 m 12c O 5 D P� <br /> UuCFr�&t 12948M FLEETCZ23.4 <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are f0y 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 EPA Acknowledgment of Consent. <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 am a small quantity generator)is true <br /> enerators �erors Prnted/Typed Name ignature� Month Fay ear <br /> I G5 1�0 JOB <br /> 1 16.International Shipments ❑ <br /> H Elimportto U.S. Export from U.S. Port try/exit: <br /> Transporter signature for exports only): Dale leaving U.S.: <br /> LM 17.Transporter Acknowledgment of Receipt of Materials <br /> W <br /> Transporter 1 Printed/Typed NameSignature- Month Day - Year <br /> a SEAN SPITZEF3 0 5 120 IO 8 <br /> Z Transporter 2 Print d Name gnature Month Day - Year <br /> a C <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection_ El Full Rejection <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> Q 1. <br /> LL Facility's Phone: <br /> W 18c.Signature of Alternate Facility(orGenerator) Month Day Year <br /> Q <br /> Z <br /> N <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator Certification of receipt of hazardous materials covered by the manifest except as noted in Item l8a <br /> PrmtedlTyped Name /� Signature Month Day Year <br /> tt&0f6 AR SAA Au'do'POW(R808hrld w II secest are w3sts-the generatoiSID FACILITY TO GENERATOR STATE(IF REQUIRED) <br /> 10413.0104 <br />