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SSL SK SHIP# 235244062 (I (� I� I� 1111111 <br /> 0 0 8 1 4 3 4 8 0 S K S <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Pagg 1 of 3 Error icy gp�sep p 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS CAR000039370 1 t—ts�i0-4bt3—l�t� ��(� <br /> WASTE MANIFEST on14 48on <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Escalon Premier Brands Inc. <br /> 1905 Mchenry Ave <br /> ESCALON CA 95320-0000 <br /> Generator's Phone: 209-552-6051 <br /> s.r ggpor1e41 Compary�pl�ge SYSTEMS INC U.S.EPA ID Number TX ROt 00812 f <br /> 7.Transporter <br /> �2YCo tm'paanyy Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MAD039322250 <br /> 8.Designated Facility Name and Site Address CLEANHARBORS OF BUTTONW I LLOW U.S.EPA ID Number <br /> 2500 LOKERN ROAD <br /> BUTTONWILLDW , CA 93206 <br /> 661-762-6200 CAD98067527G <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 <br /> HM <br /> and Packing ou (if any)) No. Type Quantity Wt./Vol. 13.Waste Codes <br /> t. N1. ON CRA HAZARDOUS WASTE SOLIDS' I DEi P 352 <br /> o (GREOSE), RAQ%,,, J IL <br /> a <br /> W z. N NON RCRA HAZARDOUS WASTE SOLI S12 , - 1?h1 P 352 <br /> (ABSbRBENTS CONTAMINATED WITH OIL), lsh(pV- 1 4� <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD i BL 87225346 ES 1201 <br /> eta LA 16Sy� <br /> 24H EMERGENCY#800-468-1760-CH/SK/TFI-Contract retained by generator confers aggency authority <br /> on initial transporter to add or substitute additional transporters 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 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.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 EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)if I am a small quantity generator)is true. <br /> G n ators/Offeror's Printed/Typed Nameture Month Day Year <br /> 7U 0 ii` S 0" Z <br /> 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Tra porter 1 Printed/Typ aml Sign a Month Day Year <br /> a <br /> L� z� <br /> Z Transporter �nted ped Name Sign ure Month Day Year <br /> G y <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> U <br /> Facility's Phone: <br /> LU 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU <br /> C 1 132 2. I�^ 3. 4. <br /> H20.Designated Facility Owner or Operator:Certification of receipt ofhazardousmaterials covered by the manifest except as noted in Item 18a <br /> Pnnted/Typed Name Signature Month Daayy Year <br /> LPAW <br /> J <br /> EPA Form 8700-22((Rev.12-17) Previous editions are obsolete. DESMATtD FACILITY TO EPA's e-MANIFEST SYSTEM <br /> 1)8681139/187973 2)8E84282/1879289 <br />