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ER SHIP# <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page,1 of 3.Eme�tpt�C RespoArse Phong, 4.Manifest Tracking Number �((1 <br /> WASTE MANIFEST `u_'rl t SKS <br /> 1 3 ,� <br /> 5.Generator s Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> ,0Esca)on Preni.er Brands Inc. <br /> . 1005 Mchenry Ave <br /> ESC€1LON CA 95320-08119 <br /> Generator's Phone; 209-552-6051 <br /> 6.Trip Co n U.S.EPA ID Number <br /> _•t` `lt't'� SYSII:i�iS INC ��0tJ918fl2+D , <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 1 f_EAN HARBORS ENV SVC INC. T4 3 „ °i r'! <br /> 8.Designated Facility Name and Site Address CLEANHARBORS OF BUTTONW ILLOW U.S.EPA ID Number <br /> 2500 LOKEAN ROAD <br /> BUTTOW I LLOW , CA 93286 <br /> 661-762-6200 <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codas <br /> HM and Packing Group(if any)) No. Type Quantity WLAIoI. <br /> 1. y NON RCRA .;"'R^n'J5 WASTE SOLIDS, D!M r; 352 <br /> (ABSORBENTS CC7�v'„�„ '.;:I;ED w-crh OIL), 4fFr^ <br /> ,iL <br /> W 2 NO�i RCRA HAZARDOUS WASTE SOLIDS, � P 352 <br /> cs (GREhSE), ` <br /> rt. as Doh 1 fop <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD-.BL 84573290 E512014 CSG I <br /> V <br /> 24H EMERGE':NCY*800-468-1?60-CH/SKITFI-Contract retained by genler for confers are c�fr#fori' y <br /> on i.n)tia] trans arter to add or substitute additional trans orfprs on .IYrra r► � r,^��lf- <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the conlgnts of this consignment are fully and accurately described above by the proper shipping name,aro are classified,packaged, <br /> marked and labeled/placarded;and are in all respects in proper condition fortransport according to applicable intemallonal 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 EPAAclmowledgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(f I am a large quantity generator)or(b)('dl am a small quantity generator)is true. <br /> Generator's/0fferor's Printedrryped Name Signature Month Day Year <br /> ;16.Intemationa!Shipments <br /> ❑Import to U.S. ❑ExpOft from U.S. Port of eotiylextC <br /> ? Transporter signature(for exports only): Data leaving U.S,: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> ul <br /> Transporter 1 Printecirryped Name Signature Month Day Year <br /> z Transporter 2 PdntWyped Name mMonth Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type �` ❑Residue ❑Partial Rejection ❑Full Rejedion <br /> Manifest Referwme Number. <br /> 18b.Alternate Facility(or Generator) . U.S.EPA ID Number <br /> U <br /> LL Facllily's Phone: <br /> w 18c.Signature of Altemate Facility(or Generator) Julonth Day Year <br /> Q <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatmenl,disposal,and recycling systemsy <br /> 2. 3. 4. <br /> l � <br /> 20.Designated Facility Owner or Operator.Cerd4ationof receipt of hazprdous materials covered by the manifest except as neled in iem 18a <br /> IMped Name Signature / Mono Day Year <br /> EPA 1ff4 d�iyvl 182�11Pios�edt�o�ses�l�t�79273 DESIGNATED FACILITYTO GENERATOR <br />