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SSL <br /> �� �r�l ' Bs2f�'097A7 <br /> Please print or type.(Form designed for use on elite'(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Page t of 3. m R s se P 4.Manifest Trackm Number <br /> UNIFORM HAZARDOUS ,. ARQc7p 9 e F� ° _IQ 0 O �,/ <br /> WASTE MANIFEST n <br /> 5.Generator`s Name and Mailing Address Generator's Site Address(if different than mailing address) ; <br /> ire <br /> Premier Brands Iw, <br /> E, <br /> IMchenry Ave <br /> ESCALON 1�4-55 -t�051 'CA 95res�-96@1 <br /> Generator's Phone: <br /> 6.T C,o any f a$t ' U.S.EPA ID Number T O Q i M <br /> Ht I'r^2St�r l- ! SYSTEMS IPTG <br /> 7.Transporter 2 Company Name. U.S.EPA ID Number <br /> CLEAN HARBORS ENV I RGNME dTAL SVC INC. MAD03922' 250 <br /> 8.Designated Facility Name and Site Address CLEAPRfIdRBORB O= BUT.TOWILLOW U.S.EPA fl)Number <br /> K9!10 i_JKERN ROAD <br /> 8U TT G; iJ I LLOW , GA 932MGAD950f�7 � <br /> Facilit es Phone: <br /> ga. 9b.U.S.DOT Description(nduding Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(fi any))- No Quantity WU1lol. <br /> X I. PIS UO2 HAZARDOUS WSTE LIQUID -w , S Ioii 135 <br /> o N.O.G., (SILVER ), .9, pod- III , � <br /> 1_ C�r,l 1 Il{ <br /> 3. C-Im L= u <br /> SEP 1.16 <br /> 4. eu <br /> BY _ <br /> '4.Special Handling Instructions and Additional Information T `D aBL 7_7*'t5W_ ESI r <br /> EP <br /> 24H Ei"ERG �C-YttBW--4fiB-l�N-CH/SK TFI-Contract retained by generator confers . envy author0y <br /> on initial tr-allisporter .to add or substitute, additional tr'ana orters on - enerator*s behalf. <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are dassified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Eiporter,I certify that the contents of this consignment conform to the terms of the attached EPAAclmowledgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 26227(a)(if I am a large quantity generator)or(b)(If tam a small quantity generator)is true. <br /> Gene oe$l0Trors Pnntedrr '.-d N m SignatureF �'" Month Day Year <br /> Y_ J�'i x`/1 /11- 3 1d <br /> —r 16.Inter"rYaUtinal Shipments <br /> .- .0 Imp-4t to U.S: ❑Export from U.S,,-,-- Pod'of entrylexit• <br /> a Transporter signature(for exports only): Date leaving U.S.: <br /> tL 17.Transporter Acknowledgment of Receipt of Materials ' <br /> R Transporter 1 Printed(T ed Name Signature Mo h Day Year <br /> d to � � oe't� I" !��nJ . <br /> Q Transporter 2Pdnted oOName Signature Mo #Day Yeara <br /> 16.Discrepancy l 4 <br /> 18a.Discrepancy Indication Space <br /> ❑Quantity ❑Type 0 Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number- <br /> 181b. <br /> umber18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> :3 a <br /> U _ <br /> Fadlitys Phone:. l <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> K <br /> 19.HazarrddouusAbste Report Management Methgd Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 4. <br /> 20.Desigriate&I'aci' ner or-0peratk..Certification of fecal f h�ardous materials covered by the manifest except as noted In Item"18a., <br /> Printed(ryped N e Signature Month y e <br /> EPA o 8 2 v r u edi'0 <br /> ' DESIGNATED FACILITY TO GENERATOR <br />