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} <br /> 481904827674-00.1 SC PPW 7!!2/2018 <br /> Please print or type.(Form designed for use on elite(12-pitck)typewriter.) o4 Sam.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page t of 3.Emergency Response Phone 4.Manliest 7racktng Number <br /> WASTE MANIFEST C 0 0 2 9 6 i 4 7 3 � (800)483-3711 011848923 F L E <br /> 51Ht)Ufl !fl riQU5e WA *yr <br /> reatment Plant Generator's Site Address(if different than mailing address) <br /> 18045 Kelso Road SAME <br /> Mountain-12811 fNm <br /> Generators Phone: <br /> Transporter I Company Nam U.S.EPA ID Number <br /> Clean Harbors Environmental Services,Inc- MA D 0 3 D'3 2 2 2 5 0 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8. tiY Name and Site Address U.S.EPA ID Number <br /> BAKERSFIELD TRANSFER G A L vii v 2 8 2 5 3 fl <br /> 1620 E.BRUNDAGE LANE <br /> Bakersfield.CA 93307 <br /> Facilitys Plane: (66i1322-8258 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(d any)) No. Type Quantity Wtivol. 13.Waste Codes <br /> w 1NON-RCRA HAZARDOUS WASTE,LIQWDS,(DESEL,WATERT 3 <br /> 0 1 TZ' >�D 6- <br /> z 2. <br /> W <br /> c9 <br /> 3. <br /> 4. <br /> t4_S) (t� n9 IQsqu�d Additional Information <br /> 11 Uai �JJ c�J kgko LCk 5c�k <br /> Contract retained by aenerator c nim 3Genc-t alrnarity on inlfiai trarlsmic-to add f_r Smubstrute additional tra-isoorters on renE.,atoPs behalf <br /> 15. GENERATOR'SrOFFEROR'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 labek dlplacarded,and are in all respects in proper condition for transport according to applicable intemational 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 terns of the attached EPAAcknowledgment of Consent <br /> I cer4fy that the waste minimization statement identified in 40 CFR 26227(a)(if I am a large quantity generator)or(b)C9.1 am a small quantity generator)is We. <br /> nor on <br /> ft/It_6C.1 <br /> 16.International Shipments <br /> 1— ❑import 1114S. Export Born U.S. Port of entryleAt <br /> Transporter sonature for ex onl Date leaving U.S.: <br /> fx 17.Transporter Admoxdedgtrhenl of Receipt of Materials <br /> Tr�a °�` `1 Print yped Name ria ra Mr <br /> a. <br /> �[ OriY.. l.l.eS a.� f o a y l <br /> 5E Transporter 2 PrintediTyped Name signature y ear <br /> 1 <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full R*W. <br /> Manifest Reference Number. <br /> 18b Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> Q <br /> u- FecUqs Phone: <br /> Q 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Z <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. F <br /> 4. <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materiels covered by the manifest except as noted in Item 1 as <br /> PrintsdTypedl Name Signa Month Day Y <br /> r, 1r v <br /> EPA Form 8700-22(Rev.3-05) Pr vious edition are obsolete. WMfNATED FACILITY TO DESTINATION STATE(IF REQUIRED) <br />