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SSL SK SHIP# 217510153 <br />- Please print or WD (Form desianed for useon elite (12 -pitch) tvpewdter.)- 1'bl� "7 <br />N I till III f i l l 1!1!11 II III Il till I II I !II <br />0051058265 KS <br />Form Approved. OMB No. 2050-0039 <br />EPAFSyhn9Zl]WVd5)1P.!y0ous editions are obsolete. DESIG;WATED FACILITY TO DESTINATION STATE (IF REQUIRED) .. <br />UNIFORM HAZARDOUS <br />1. Generator ID Number <br />CAL00@393929 . <br />2. Pag of <br />3 cy se <br />- ` -�+6 - <br />1. Manfest Tracklnp Number <br />O. C �1 p 2 6 i� KS. <br />00'.51.6.5.826 <br />WASTE MANIFEST <br />.(1.5 <br />V <br />Q G v u n <br />5. Generator's Name and Mailing Address Generatoes Site Address (if different than multi address) <br />rile? errhauser <br />2700 S California St <br />STOCKTON CA 95206-0000 <br />Generators Phone: 209-373-8256 <br />6. T9fflr[V-2Rttbr SYSTEMS, INC. <br />U.S. EPA ID Number <br />TX R000O81205 <br />7. Transporter 2 Company Name <br />U_S. EPA ID Number <br />/ <br />6 <br />8. Designated Facility Name and Ste Address GLEAN HARBORS ARAGONITE LLC <br />U.S. EPA ID Number <br />11600 NORTH APTUS ROAD <br />ARAGONITE , UT 84029 <br />435-884-8100 <br />UTD981552177 <br />Facil' s Phone: <br />ga, <br />91b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, 10 Number, <br />10. Containers <br />11. Total <br />12. Unit <br />13 Waste Codes <br />No. <br />Type <br />HM <br />and Packing Group (if any)) <br />Quantity <br />WL/Vol. <br />X <br />t NA1993 COMBUSTIBLE LIQUID N. 0. S. <br />DF <br />P <br />331 <br />o <br />(PETROLEUM DISTILLATES), CbMBUSTIKE <br />Q <br />LIQUID, PG III <br />z <br />2. <br />LU <br />c9 <br />3. <br />4. <br />LL <br />14. Speclal Handling instructions and Additional Information TSD : AG 68574386 WE25333 <br />CSG: <br />1)ERG#128• <br />24 HR EMEfhGENCY #1-800-468-1760 (SK / TFI) <br />SEE ATTACHMENT <br />15. GENERATOR'SIOFFEROR'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 labefed/placarded, and ere in all respects in proper condition for transport according to applicable international and national govemmental regulations. If export stipment and I am ere Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br />I certify that the waste minimlmiion statement Wended in 40 CFR 262.27(a) (If I am a large quantity generator or (b) (x I am a small quantity generator) is true. <br />Genera <br />roe Printed/Typed Name Signa tir / <br />Month Day ear. <br />/� U // <br />I O I <br />J <br />� <br />*International Shipments <br />❑ Impod io U.S. ElExport from U.S. Pon of erdrylexik <br />lu <br />Z <br />Transporter signature (for exports only): Date leaving U.S.: <br />LU <br />17. Transportat Acknowledgment of Receipt of Materials <br />= <br />a <br />Tran r 1 Printed/T ame Signa <br />MaMh Oar Year <br />t� z <br />CL <br />cu e v dA <br />i� <br />Z <br />Transporter 2 Pdnta6 Typed Nae gna <br />Monti Day Year <br />�s <br />18�issdttp�Itcy <br />_ <br />18a. Disaepancy Indication Space ❑ Quantity ❑ Type ❑ Residue <br />❑ Partial Rejection <br />❑ Full Re)ection <br />Mandest Reference Number: <br />18b. Altemate Facility (or Generator) <br />U.S. EPA ID Number <br />J <br />U <br />Facil o Phone: <br />W <br />18c- Signature of Apemate Facility (or Generator) <br />Montle Day Year <br />Q <br />Z <br />(? <br />ti <br />19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />0 <br />1. <br />2. <br />3. <br />4. <br />1 <br />20. Designated Facility Owner or Operator. Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br />Pr 1 Nano Sig <br />Month Day ear <br />f' <br />EPAFSyhn9Zl]WVd5)1P.!y0ous editions are obsolete. DESIG;WATED FACILITY TO DESTINATION STATE (IF REQUIRED) .. <br />