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case print or I ;Form ed for use on elite (12.pfchl typewriter.) Form Approved OMB No. 20500039 <br />UNIFORM HAZARDOUS I Ceneraw ID Norther 2 Page 1 of 3 Efnergenelp nespom P.Sm A. fMan Treekho r <br />WASTE MANIFEST cocFqnr. i 1100-W35-Ds3 Illfotrao 010 4 016 72 FLE <br />"��•' N' "rwd ` ' GS Mining Company LLC " IrtanmipkV addressl <br />PO Box 679 Golden Gilpin Mill, CO Hwy 119 <br />c.j&4ftwk, CO SX22 Bieddta K CO 80422 <br />""p0rkir It s EPA Num w <br />AET ENV ROMWENTAi, INC. <br />I -ra®lpoder 2 Coirpany Name <br />SAVANNAH TRANSPORT, INC. <br />aostyNan'ear" <br />100:{85 H. HIGHWAYY 3 38 0 CLEAN HARBORS ENVIRO SVS, INC - Door Trail <br />DEER TRAIL, CO 80105 <br />Fa,",,Ph. 870 388.2283 <br />I9a I 9b VS DDT Desodpasa f ir1dL*V Prop- Stttppng Name, Hazard Class. ID Number. <br />HM and Patlung G W 111 arry <br />1 1: �+11Lr-4,'<.in..;t to, .4iL..rti C.�,a, d. {1l .kilt_ so-. <br />T L l.. is . C : Kc'... S �. , ti+s.l., <br />•a=.�aII�� <br />10.10. Conlaioers <br />No I Tyr. <br />C i I br <br />a: 1711- <br />9 Irll- <br />50000336801 <br />CODS91300484 <br />11 TOW 12, Lw 13 Yye51aC_3&s <br />(wintity Wt A" <br />1v*1 <br />it E! <br />7.3, 61 r <br />15 GENERATOWSIMEROR'S CERnFICATION: I hereby darfars stat the contents or pro coMv gl W are fuYy end amratNy despibed above by the prop- st" row. and aro ciasslGed package <br />marked and vbe"ptacarded. and we ins• respech in proper eartAaion for ffA 3W Woording to applicable inlemalional oral nahortal <br />gdvafMteraal regUlafiana II elport alypmant and r am the Pranary <br />Eeportor. I car4tl Ural the tXatlenh aT this rnrtergrmenl oonlorm h ilia terms d the allaslted fPAAdulorv{edgmenl of Consent, <br />I gartdy that tho waste mnimuaWn swemenl idoNirrrd hoe CFR 262 21W fil I am a hope quantity9mwakor)or {bl?tIr am a" Quart iy ge icralar) is bre <br />+. v's y5rt Nlerq ue , <br />�LZ� L �1••.��5 ori Bc�aC-r � �S 1�►�fN' <br />r <br />❑ Import to V S ❑ E'w from Us Port of enityhot: <br />" a soarlcr azul aa?lu <br />ON *a "i Date V S <br />'renspatr Acknowleeg al of Receipt of Matenah <br />ru.slraler t Pruy�yt IIrtI tra.we <br />Ia Dinvirency <br />Ipa.DwaparuylndaatinSpace _ ';Janbty UTYPe R.M. ❑ Partial Repction <br />krardesi Rclmtstce <br />iSemakFaallylaGcroaturl LfS EPAID.Ytrrtbc <br />a <br />LL =. <br />'E mazer "Waste Repmr Mr e;;`e,l hleprod Codesp a zits lor haterdow wash oNgWeM disoosal'nd <br />a <br />2C DvsyuNcd Fir Dr OPe— -wnr iA oT receipt of rtazarootq mawals wowed by rhe manifest except ea noW or, hum laa <br />�nreWTrlra4 Na": ---�.R.- <br />?A Fara 5'JO 22 • Ke ~ -05) Previous e: • --,s are obsolete —�� — <br />M@2ffl lE <br />Full Roped -ion <br />