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GJ iG0328i22(3-)Gi SC. PI -VU 7/20/2015 Please print or type. (Form designed for use on elite (12 -pitch) tvoewriter.) r„rm A i n,ao hi Oncn Anon crm rurm otuu-zz lmev. a -vol r-rewous editions are oosolete. D;:SIGNAT ED FACILITY TO DESTINATION STATE (IF REQUIRED) Clean Harbors has the appropriate permits for and will accept the waste the generator is shipping. , ........ V 1 •'u ' •v LV V V V V V y A UNIFORM HAZARDOUS 1. Grnto P go l o 1 4. Manifest Tracking 8Ddug.N..u.m..brer O . AqK1 3 WASTE MANIFET 1008858710 FLE 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) Ferguson 630 Poet Of Stocktork St SAME Stockton. CA 55203 Generators Phone: If2, 6. ransporter 1 ompany ame U.S. EPA ID Number Clean Harbors Environmental Service, Iris. MAO 0 3 9 3 2 2 2 5 0 7.Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address U.S. EPA ID Number Cleary Harbors Aragonite LLC 11600 NorthAptus Road U Ia $ FaRipp S`n�!He. UT 84029 (42CMIRGII 84:00 ga. 91b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 11. Total 12. Unit HM and Packing Group (if any)) Quantity 4Vf Nol. 13. Waste Codes No. Type a UNi950, WASTE AEROSOLS, 2.1 X 00i DF 000135 P I 2E I f 2E 0 2. UN1993, WASTE FLAMMABLE LIQUIDS. N.O.S., (ACETONE, QO01 D035 551 X METHYL ETHYL KEYTONE1. 3. PG If 005 D M 015 9 1 t' 3. UN3266, WASTE CORROSIVE LIQUID. BASIC, INORGANIC. _ x N.O.S.. CSOQIUM HYDROXIDE. SODIUM HYPOC'HLORITEI. 9. PG 0 0 i D F 00120 P 1 -0021-55;L M1 (i 11 4. UN32 4,WASTEC-ORROSIVELIQUID. ACIDIC, INORGANIC., D002155i � x N.{3.5., (IIESCALESULFURIC ACID). S. Felt 0 01 D F 0 0 2 4 9 PR, - .,-. ....._..,...�. r 14. Special Handling Instructions and Additional Information r L[ET#S 5547 1_LCCRQ ERC -#126 1X30 2-LCCRD ERG#128 5X55 3_LCCRB ERG#154 1X30 4_Le' 15. GENERATOR'SIOFFEROR'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, marked and labeled/placarded, and ate in all respects in proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary Exporter, I cerlffy that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (f I am a large quantity generator) or (b) (if I am a small quantity generator) is true. Generator Offerors Printed/Typed Name Signature X, Monthay Year LORALIE MAC:ASI NAG(if :� !�/' �� J.(:-, -t F- 16. International Shipments ❑ Import to U.S. ❑ Export from U Port of <11 exit: - Transporter signature for exports only): Date leaving U.S.: W 17. Transporter Acknowledgment of Receipt of Materials oTransporter 1 Printed(Typed Name Signal re Month Day Year rlMIKE BRUNYANSKY 1UIn its Q Transporter 2 Printed/Typed Name Signature Month Day Year f- 18. Discrepancy 18a. Discrepancy Indication Space Quantity ❑Type El Residue El Partial Rejection ❑Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number U Q LL Facility's Phone: w 18c. Signalure of Alternate Facility (or Generator) Month Day Year Q C9 LU 19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) LU 1 2. 3. 4. H141 H040 H040 H040 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a Printed/Typed Name Signature Month Day Year crm rurm otuu-zz lmev. a -vol r-rewous editions are oosolete. D;:SIGNAT ED FACILITY TO DESTINATION STATE (IF REQUIRED) Clean Harbors has the appropriate permits for and will accept the waste the generator is shipping.