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P type.. <br /> Please rotor Form Approved.OMB No.205p 0039 <br /> UNIFORM HAZARDOUS 1.Generator or ID Number 2.Page 1 or 3.Erne genry Response Ptrona !.ManHestTracking Number <br /> WASTE MANIFEST C-,,irC�CjVMV,:. 1 7 » ? 024899,98n JJK <br /> 18 <br /> 5.Generator's Norma and Haling Address Generetors Site Address(it different 0tan mailing address) <br /> C4_TRAAJS DISTRICT d 44�-:C"_ <br /> 111 GPgM AVE 12TH FLOOD FTE-,&-.POS t:1!�;.W <br /> OA:CLAIdD.CA 94512 TTD!JILT_H. U VeRMORE C4 945W <br /> GeneraWl's Ptanb ii-:i�"r67v <br /> 6.Trarsponer 1 Company Name U.S.EPA ID Number <br /> ff <br /> 7 Transporter 2 Compa r Name U.S.EPA 10 Number <br /> 8 Designated Fa,,Hy Name and Sit,Address U.S.EPA ID Number <br /> Clear.Harbors BtttiOn:alllDt�r LLC <br /> 2500 W.ESt LoF..Ern Road Yd7:Yn?sL1 S <br /> 800IT IlGm,CA 932D5 <br /> 661-762.62� <br /> FaaLry's Phone: <br /> go, 9b.U.S DOT Description('Including Proper Snipping Name.Hazard Class,ID Number, <br /> Hid and Packing Group(if any)) 10.Containers 11.Total 12.Unit <br /> 13. <br /> No. Type Quantity WL/VOI, WasteC:.des <br /> 1 UPJ3C?7 Etv'�1ROMchrTaJL tiA2aRD0!IS S!t957.41dCcS, SOLID, Doi OT i.3 y =1t <br /> 9,PG III <br /> w <br /> Z 2 <br /> w <br /> to <br /> I <br /> 3 <br /> 14.Special HandJfrtg Irsuucbons aM Add tonal Iltformation <br /> 2J57 E1",GV171 <br /> � =23oE9ggbti-L <br /> 15 GENERATOR'SrOFFEROR'S CERTTJCATION:I hereby declare that the contents or dus consignment are fully and acaretely described above by the proper shipping name,and are dassified,packaged. <br /> marked and labelediplacarded.and are In all respects in proper condition for transport according W applicable international and national governmental regulatiats.If export sttipm,m atd am the Primary <br /> Exporter,)certify that the contents of this consignment mnlonn W the terms of the attached EPAAcknow:edgment of Consent. <br /> I"ll/that the <br /> waste nenirtdzallon statement idenMed in 4G CFR 262.27(a)(If I am a large quantity generator)or(b)(if I am a small quantity generator)Is true. <br /> Gecer@ta's(0:feror's Printedftyped Name Signature month Day Yew <br /> kp,l M 2 <br /> 1G.International Shipmenrs - <br /> i- ❑Import to U.S. ❑Export from U.S. Port of ermylexk: C. <br /> Z Transporter signature liar exports only): Date leaving U.S.: <br /> w 17.TranspadarAdvi"edgment of Receipt of Materials <br /> Trans r 1 PdntedTypad Name <br /> O SlgnaMa nwm Day Year <br /> Transporter 2 P1-1—TLyyedG-- �� Sign a G� b <br /> Month Day Year <br /> f- <br /> 4I4I4I 18.Discrepancy <br /> I 18a.Discrepancy Indication Space Ouantity ❑Type <br /> ❑Residue ❑Partial Refection ❑Full Rejection <br /> 18b.PJtemate Fac(Ity(or Genermari Manifest Reference Number. <br /> U.S.EPA ID Number <br /> - U <br /> u Fora ily5 Phone. <br /> w f k Signature of ANemate Facility(or Generator) <br /> Q Month Day Year <br /> 2 <br /> CD 19.Hazardous Waste Report Ntanagement McOad Codes(le.,codes for hazardous waste treatment.disposal,and recycling systems) , <br /> 17 / 5 3, 4. <br /> 20.Designated Facility Omer or Operator Cenlricadon of receipt or hazardous materials covered by the manifest except as noted in Item 1 as <br /> FYi edTypM Name .naU <br /> MonUt Day Year <br /> EPA Form e700-22(Rev.12-17i Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br /> �, YY <br />