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Plaaca nrint nr hma (Fnrm rtasinnPd fnr Tisa nn elita (12-nitrh) Ivnawriter.I GJ u`• 032fr°.t_226-0'Ui se PPP ' 20/m1i 5 Form Aooroved. CMB No. 2050-0039 <br />EPA Form 8700-22A (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />Clean Harbors has the appropriate permits for and will accept the waste the generator is shipping. <br />UNIFORM HAZARDOUS WASTE MANIFEST <br />Generator ID Number <br />22. Page <br />23. Manifest Tracking Number <br />(Continuation Sheet) <br />121. <br />C_ A L 0 0 0 3 4 4 3 9 4 <br />2 of 2 <br />0009513710FLE <br />24. Generators Name <br />�'Hli''�trSrRFt <br />U.S. EPA ID Number <br />25. Transporter Company Name <br />U.S. EPA ID Number <br />26. Transporter Company Name <br />27a. <br />27b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />28. Containers <br />29. Total <br />30. Unit <br />31. Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />5. NON-RCRA HAZARDOUS WASTE- LIQUIDS. (LUBRICANT. <br />551 <br />PROPYLENE GLYCOLi <br />004 <br />D M <br />00820 <br />[' <br />....... <br />E. NON-RCRA RAZARDOUS WASTE. LIQUIDS. (ANTIFREEZE. <br />551 <br />SILICONE) <br />003 <br />D M <br />00724- <br />P <br />_....._........... <br />................ <br />E t <br />7. NON-RCRA HAZARDOUS WASTE. LIQUIDS. (SEALANTS. <br />551 <br />LUBRICANT) <br />00i <br />DM <br />00240 <br />P <br />1 1 ( <br />S. WASTE NON-RCRA HAZARDOUS WASTE, LIQUIDS. (FLUX, <br />r <br />551 i <br />oi..._...... <br />a <br />SEALANTS) <br />002 <br />D M <br />00495 <br />P <br />....... , <br />I <br />w <br />w <br />9. NON-RCRA HAZARDOUS WASTE, LIQUIDS, (LUBRICANT, <br />551 <br />0 <br />SEALANTS) <br />001 <br />D M <br />00400 <br />p <br />............ <br />i <br />10. NON-RCRA HAZARDOUS WASTE, LIQUIDS, (LUBRICANT) <br />551 <br />001 <br />DF <br />00075 <br />P <br />_.. ......., <br />f <br />(E ............... <br />i ) <br />i <br />1 f <br />3 j <br />1 <br />r <br />t 1 <br />32. Special Handling Instructions and Additional Information <br />5-LCCRN 4X55 5.LCCRN IX55 <br />6.LCCRN SX55 10.LCCRN 1X00 <br />7-LCCRN 1X55 <br />S . LCCRN 2X5.5 <br />Ly <br />33. Transporter _AcknozAed ment of Receipt of Materials <br />F <br />Pwtedllyped Name Signature Month Day Year <br />O <br />IL <br />0 <br />34. Fransporter Acknowledgment of Receipt of Materials <br />Printcd/ryped Name Signature Month Day Year <br />H <br />35. Discrepancy <br />J <br />U <br />Q <br />LL <br />A <br />Q36. <br />Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />5.1-1040 B. H040 7. H040 S. H040 9. 1-1040 <br />LU <br />LU <br />0 <br />10.1-1040 <br />EPA Form 8700-22A (Rev. 3-05) Previous editions are obsolete. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />Clean Harbors has the appropriate permits for and will accept the waste the generator is shipping. <br />