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530948-22 ERI Provider: Clean Earth 4939552 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) <br /> NONHAZARDOUS T Generator 10 Number 2 Page f of3 Fmergency Rest>nese Phone4.Waste Tracking Number <br /> WASTE MANIFEST CAR000223776 1 (877) 577-266 53094 <br /> 02 o'Z <br /> (+V 5 Generator's Name and Malting Address Generator's Site Address rif different than mailing gess) <br /> 60 Nope 9epot C/O PSC Rttn. Hoye Depot CSR RM lepot 6661 <br /> 5151 Triangle Parhwy, Suite 1 16 2968 REYNOLDS RA(N;H PARYY <br /> 4 Generators Phone PEACKTREE CORNERS 6A Mill (219)263-6111 LODI CA 95241 <br /> 6 Transporter 1 Comny Name �'J g c14 S Number <br /> 11 CLEAN EpaARTH SPECIALTY WASTE SOLUTIONS MNS000110924 <br /> Transporter 2 C.crhipanv Name U S EPA to Number <br /> 8 Designated Facility Name and Site Address U S EPA 10 Number <br /> Clean Earth Specialty Yaste Solutions - Rancho <br /> 3311 Fitzgerald Road <br /> Fauldy'sPhone Rancho Cordova, CA 95142 19161 225-1121 CAL000467839 <br /> 9a 9b U S DOT Descnplion Nnduding""Over Shiopirq Name,Hazard Ciass. 0 Number e ;ontamers i I Tofai 12 6nw <br /> HM and Packing Group Iry anyi <br /> No TYpr: 0Uantity NI V(iI. <br /> o MOD) TREATED NO) PASTE - Do Mot Wrn or Scavoup 1 CM 10 Y <br /> ga <br /> w <br /> Z <br /> w <br /> 4 <br /> 13.Speciar Harding+nslructions and Additional inforr ,ation <br /> (11 MWPTV-11 - PRESSURE TREATED VN �D�S <br /> 14. GENERATOR'S CERTIFICATION: certify the matenaia describer above or'his manifest are rot suo;eci to federal regulantws 4t>r reporting or cper disposal.of H zardous Waste. <br /> Generat s Offenor's PrintedlTyped N me Signa'.ve Month Dal year <br /> a DA— nS Lj =&L 22 <br /> _J ?S.Intemational Shipments <br /> Import to U S 'L.Export'rom <br /> Tra po er ygnatip a dor exportsoniyl aye�ea.a g J S <br /> LU 16.Transporter.Acknowleogmert of Rete it of Materais <br /> Tran er 1 PrmtecL7,ed N Signature Month Da+ Yea <br /> CL v OLN V_ z <br /> rn <br /> Z Transporter 2 Pnnted7yped Name <br /> iSgna%,re Month Day Year <br /> t— <br /> ' �?-Oiscreparry <br /> 17a.Discrepancy lndrt:ahoa Space <br /> r Quart tV Type J Residue P <br /> atrial Relecner 1 :Gcu Retect�on <br /> r >rtantfe3t Re arerc,e Ncmoe: <br /> h ?b Alternate Vadk?v!or Gereratori w S EPAiD Number <br /> J_ <br /> V <br /> LL Facdrtv`s Pnone <br /> W '7c Signature of Alternate Pacr.ty for Gereratart <br /> Q Mohr,. day year <br /> Z <br /> C7 <br /> in <br /> w <br /> 18 Designated Facs0y Owner or Operators-erlitiication of rare+pt of mater4ais covered by Ire manifest except a>noted r Item i ra <br /> Fn.fed?y'ped Name S graure <br /> SMonth �'D}}a Yr=a, <br /> ii-NH0.tt-C-C-?f G <br /> "-DESIGNATED FACILITY TO DESTINATION <br />