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T SSL SK SNIP# 23SOOOS02 IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIINIII <br /> G 0 8 1 1 9 7 6 1 S K S <br /> Please print or type. Farm Approved.OMB No,2950-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID NUmher 2 Pa 1 of E n 4.irna— tTr�kl Number <br /> caL���39��i�0 � � �` ����' 0 0 8119761 $KS <br /> WASTE MANIFEST <br /> 5.GrWte01 Nazny1anv1 Address Generators Site Address(if different than mad'Ing address) <br /> 309 w11 it iiMCFart��illn�� Lutner^ Ki <br /> STOCKTON GA 95206--17105 <br /> Generators Phone: <br /> r� 215-462-5690 <br /> ItmE WSYSTEMS INC U,S.EPA ID Number TXR000061E05 <br /> 7.Tram oder 2 Comps Name U.S.EPA 1D Number <br /> {:LlEf�1a F1{aR QRS ENV SVC INC. 1�F;37�"c932�25� <br /> a.Designated Facility Name and Site Add— CLEAN HARBORS GRASSY MOUNTAIN U.S.EPA ID Nurmher <br /> 3 MILES EAST, 7 MILES NORTH KNOLLS EXIT 41, OFF I-80 <br /> KNOLLS , !!T 64083UTD991301748 <br /> k35-884-89115 <br /> Facility's Phone <br /> ga g6.U.S.DOT Descriphon(including Proper Shipping Name,Hazard Class,ID Number, 10-Corea am 11.Total 12.Unit 13.Waste Codas <br /> HM and Packing Gmup(f any)) No. I —T—ypi Quantity Wt.fvol, <br /> NL7N-RCRp NAZ€iRDIIUS WWI TE, SQLIII, DM P lei <br /> o AB5#7R1IEh1T ANTj Q1L), td�`€i-- <br /> Lu <br /> c-9 <br /> 3. <br /> 4. <br /> 14.special Harrdhrg Instructions and Additional Information TSD1 GM 87972582 OR14472 CS6- <br /> c4H EMERGENCY#COO-458-17610-CHYSYITFI-Contract retained by generator confers agency alxtYlerit <br /> on initial transporter to add or substitute additional transporters on eneraEor's kkehalf. <br /> 15. GENERATOR'S10FFEROR'S CERTIFICATION!I hereby declare that the contends of this consignment are fully and accurately described adave by the proper shpptng name,and are classified,packaged, <br /> marked and labeleftlecarded,and are in all respects in proper condlSon for transport according to applicable International and national governmental regulations.S export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignmem conform to Me terms of the attached EPAAcknowledgment eF Consent. <br /> I oeday that the waste minimization statement identified in 40 CFR 252.27(a)(if I am a large quantity generator)or(h)(91 am a small quariiry genaratm)is We. <br /> G torsrOtferors Printed(iyped NameMonth Day Yea <br /> � Sig 1�,) � a <br /> J 16.international Shipments <br /> H - Export <br /> 11 Impart to U.S. <br /> from U.S. Pad of enhylexit <br /> ? Transporter signature(for exports only) Data leaving U S.' <br /> W 17_T r Acknowladgni of Receipt of Materials <br /> Tra o PriritetllTy ame SK'131d M Day Yeer, <br /> i as a <br /> dZ ranspoder2 P-kadffyped Name Signature Mouth Day Year <br /> a <br /> w <br /> 18.Discrepancy, <br /> 18a.Discrepancy indication Space ❑Quantity LIT" ❑Residue ❑Parti ejeclian ❑Full Rejection <br /> Manifest Reference Number, <br /> 1Ito Alternate Facility{or Generator) - U.S.EPA ID Number <br /> J <br /> U <br /> rat FaaliVs Phone' ' <br /> W 1 Be.Signature of Aitemate Facility(a Generator) Month Day Year <br /> a <br /> z <br /> N19.Hazardous Waste Report Management Method Codes(i.e.codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. 3. 4. <br /> 20.Designated Facility Owner a Qperamr Certification of receipt of hazardous materials covered by the manifest exoeptas noted in Item 183 <br /> PrintedfTyped Name Signature Momh Day Yrsar <br /> EF 7F�.skr1C,77Y+ 3..nYhtrfious editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />