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sISL. , SH Pik '23382041 <br /> Please print or type. (Form deslgned for use on elite (12-pitch) typewriter.) Form <br /> UNIFORM HAZARDOUS f . Generator ID Number 2. Pae 4 o s 4. ManMgstTracking Number <br /> ved. OMB No. 2 50 0039 <br /> WASTE MANIFEST <br /> IIIIIIIIIIAN CAL�e49ss �� OS 192975 S S <br /> 5. Generator's Name and Mailing Address Generators Site Address (if diiferentthan mailing address) <br /> Gordan Trucking Inc <br /> 12550 S Harlan Rd Attn Bob <br /> LATHROP CA 9533@f-8744 <br /> Generator's Phone: 209-640-0555 <br /> s ii W-�` �'_`g°- SYf rams INC U.S. EPA ID Number TX ROM8120 <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> CLEAN HARBORS ENVIRONMENTAL SVC INC. MAD039322 <br /> 8. Designated Facility Name and Site Address CLEAN HARBORS OF WI04INGT(3N LLC U.S. EPA ID Number <br /> 1737 EAST DENNI STREET <br /> WILMINGTON , CA 9(0744 <br /> 310-835--9998 CAD04442983 <br /> Fadi s Phone: <br /> 9a. 9b. U.S.. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10, Containers 1t . Total 12. Unit i3. Waste Codes <br /> HM and Packing Group (e any)) No. Type Quantity WI <br /> ' • N(mt-RCRA HAZARDOUS WASTE, 'SOLID DM P 223 <br /> o ( COIL FILTERS) �v C1 bD <br /> Z 2. <br /> w <br /> 3. <br /> 4. <br /> 14. Special Handling Instructions and Additional lnfomraton TSD sWI 74725144 B011213 CSG % <br /> 24 HR * EMERGENCY # 1r;f.1�-468- 17W (Fri{ , TFI ) k '7 � ! r <br /> AU AS - O Y ' GEN . jQ RETAIN <br /> 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 dassified, package . <br /> marked and labeledlplacarded. and a f9 inall respects in proper condition for Uansport according to applicable infamat)ona(and nationaf govemmental regulations. It export shipment and I amine Primary <br /> Exporter, I certify that the contents of this consignment conform to the terms of the attached EPAAdw4iedgmenn ofon nt. <br /> I certify that the waste minimization statement Identified fn 40 CFR 282.27(a) (if I am a large quantity generator) or (b}(if j a small Somittly generator) is true. <br /> GeneratoeslOgeror's Printed/typed. Name Signal u " Month Day Year <br /> 18. international Ship ants 0N U, . Port of entry/exil <br /> i— import m USExport <br /> Z Transporter signature (for exports,only): pate leaving U.S <br /> 17. TrarsporterAciaawledgment ofReceipt of Materials <br /> Transporter 1 Printed oed Name Signature Month . Day ear <br /> y y l <br /> doled ypedName . off; _ nor Month Day fear . <br /> FM- fi'�7" <br /> 18. Db panty <br /> 18a. Discrepancy Indication Space El Quantity 0 Type ❑ Residue 0 Partial Rejection ❑ Full Reje <br /> 4Mandest Reference Number: <br /> 18b, Alternate Facility (or Generator) U.S. EPA ID Number <br /> V <br /> W< Facility's Phone: <br /> CA 180. Signature of Attemate FaaTdy (or Generator) Month Day ear, <br /> Z <br /> 19. Hazardous Waste Report Management Method Codes (Le., codes for hazardous waste treaafiiertt, disposal, and recycling systems) <br /> a 1, ) U 2. <br /> 20. Designated Facility. Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pdnted/Typed NameSignature Month Dey ear <br /> E0PA 74187 22 (13,. 5)7 <br /> Previous editions are obsolete. DESIGNATED FACItLITYTO GENERA R <br />