Attachment 12 _Certificate of Disposal Destruction (Example).pdf

This is a Certificate of Disposal issued by Clean Harbors PPM, LLC, documenting the proper disposal of hazardous materials from equipment. The certificate covers two separate disposal events dated 2/19/2016, involving oil drained from equipment at the job site located at 74 Washington Ave North, Battle Creek, Michigan 49037. Both items were processed using the dechlorination method at the Coffeyville, Kansas facility operated by Clean Harbors PPM.

The manifest was initiated on 10/1/2015 by generator Mr. Eric Ray and processed under EPA ID MIR000036616. The disposal service provider, Def Reutilization & Mktng Svc, received the manifest at their Battle Creek, Michigan address on behalf of customer contact Ms. Bonnie Martin. The document contains the standard civil and criminal penalty certification regarding the accuracy and completeness of the information provided, and was signed by an authorized agent on March 1, 2016. The certificate indicates two original equipment items (CH IDs 47674697 and 47674698) on the first page, and four additional items (CH IDs 47919746 through 47919749) on the second page, all classified as CM unit type equipment with corresponding serial numbers and customer identifiers.