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SK SHIP# 23ti4--*44104 <br /> V, <br /> Please print*type. Form Approved.OMB No.2050-0039 <br /> UNIFORM , RDOUS 1.GeneraTr Iftumber ag 0 m r e e s an as rac ing um er <br /> WASTE MANIFEST CAROU039370 —4 —1 , 'e C V 110% <br /> Oni�J' 413478 Sao <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Escalon Prewier Brands Inc. <br /> 19N Mchenry Ave <br /> ESCALON CA 95320-0000 <br /> Generatoes Phone: P-09-552-6051 1 <br /> 6.TgWg�l CoTfLa!�N <br /> Y _?Re U.S.EPA ID Number <br /> SYSTEMS INC <br /> 7.Transporter 2 Company Name 41 U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. 14AD0393;- <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS OF WILMINGTON U.S.EPA ID Number <br /> 1*737 EAST DENNI STREET <br /> 310-835-9998 WILMINGTON CA 90744 CAD9444236,K' <br /> Facility's Phone: I <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12,Unit 13.Waste Codes <br /> HM and Packing Gr <br /> ,' .',pup(if any)) No. Type Quantity Wt.Nol. <br /> I. NM NON RCRA HAZARDOUS WASTE LIQUIDS P 221 <br /> LESS THAN 10% WATER) N*AQ <br /> 0 (OIL W/ <br /> 3. <br /> 4: <br /> 14.Special Handling Instructions and Additional Information <br /> TSD:Wl 872f., <br /> 24H EME PGENC Y#80e-1468—I 760—CH/tiK i/TFI—Luntract retain# by generator confliI a ency authority, <br /> on initial franspo-tor to add ar 'substitute additionaf tj�anspnrtprq on gonpraggrIq b"half. <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described'above by the proper shiplTing name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.Ifexpod shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CIFIR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> toes/Offeror's Printed/Typed Name S' tu Month Day Year <br /> �'j -E 1<�- 01!7' lit <br /> _j 16.International Shipments <br /> I— I Dimport to U.S. El Export from U.S. Port of entry/exit: <br /> 9 Transporter signature(for exports only): Date leaving U.S.: <br /> OC 17.TransperterAcknowledgm*of Receipt of Materials <br /> ul <br /> nsporter I Printed yped Nam Sipiture Month Day Year <br /> �-) �J(-A I <br /> L= <br /> z I Tf6risporter 2 PrintedfTyped Name 01911dt Month Day Year <br /> A � U7 <br /> I � � C 4" L <br /> 18.Discrepancy <br /> 1 Be.Discrepancy Indication Space El Ouantity Type Residue ElPartial Rejection E]Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> Facilitys Phone: <br /> 'A 0 1 <br /> Uj 1 8c.Signature of Alternate Facility(or Generator) Month Day Year <br /> !R <br /> Z I I I <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1. <br /> 2. 4. <br /> 0,4k 1 1 <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22(Rev.12-17) Previous edifions are ci�solete. DESIGNATED FACILITYTO GENERATOR <br /> I)BP481 198/1879274 <br />