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SSL SK SHIP# i _ 362091 I _ <br />Please pfint or type. (Form designed for use on Shia (12 -pitch 'ter.) Forth Approved OMB No, 2050-M <br />EPA Fein 8700.221RV 3-94) rrayous ad one are euwnv. <br />UNIFORM HAZARDOUS 1Generator ID Number - <br />2. Page t d <br />3. EmergencyRewmw Phom <br />. Ma n <br />539848 SKS <br />WASTE MANIFEST CRL000005483 <br />1 <br />i-800-468&-'}760 <br />5. Genaralab Name and Maung Address Generators Sde Address (if diflereN than mi addmae <br />8i O Tire r ; <br />302 N Cherokee Ln <br />I_ODI CR 95240-2401 <br />Generatare Phma _ <br />8. Traapoder i CompaM U.. EPA ID Nmbm <br />SAFETY—KLEEN SYSTEMS, INC. TXROOM1205 <br />7. Trarcportar 2 Company Name U.S. EPA ID Number <br />S. Dedgnated Facility Name end See Addroeo U.S. EPA ID Nambw <br />CLEAN HARBORS RRABQNITE LI -C <br />11600 NORTH APTUS ROAD <br />gRAGONITF , UT 84029 <br />43:i-884--81fl0 UTA981552177 <br />Fedl aPhme: <br />gg <br />W. V.S. DDT Desodytbn (i ceid'mg Proper Shipping Name, Haufd Gane. to W mbef, <br />t0. Cmtdnae <br />11. Total <br />12. Unll <br />13 Walls Codes <br />No, <br />Type <br />HM <br />and Padang Gmup(dsmy)) <br />Qagry <br />WLAM. <br />X0 <br />1 NA3082, HAZARDOUS WASTE, LIQUID <br />}II <br />DM <br />y <br />P <br />D006 <br />D$07 <br />D808 <br />N.O.S., (CADMIUM, LEAD), 9, PG <br />1 <br />1 <br />f <br />? <br />W <br />2 <br />APR <br />0 7 2016 <br />4. <br />14 spedal HandIfing Inatimictans and AMdhbnW Informiraffon TSDs A13 69941413 8116849 C96P <br />I)ER13#171g <br />24 HR EMERSFNCY 41-800-468-1760 (SK ! TFI) <br />SEE ATTACHMENT <br />1 O I S(OFFEROR'S CERTIFICATION: I hereby detlme that the caneNs of he wnsignmed am kd y and aaurelety daernbed above M the payer shgpap um, $14 en d•aaiiM, packaged. <br />. <br />marked and labe'edbMmrtlad, and ere m all mspata in pDper wndrllon for trareport ac=ding b oppemdo ettemeaonal and natiaul gova Mmol fown thus. If a•port shipment end I am da Primary <br />Eworter, I rardfy Nal the wkni+h of this cnmspnenant wnfarm to he leets d the eflachal EPA Acknowledgment of Consent. <br />I oar* Fat the waste mbknbalbn stalemmt Merged b 40 CFR 28Z27(a) ill I em a targe quantity garrombr) or (b) (RI am a smell Wmdty gimm w) <br />Genan"SlDgem'sPmteill pwd Nama Siguham N Day Yaer <br />it aternatiting Shipmentsf, <br />IrtpmbU.3. ❑Emad tram U6. Pond anlryledc <br />Tmmpoaer slgnaaee Ifs amort only)_ Date leaving U.S.: <br />17. Transputer Atknewadgmad of ReDW MaWdab <br />rwd <br />MwN Dry <br />y <br />1 dnted/rlped Na Sinnature <br />N <br />7eYrampoRK-11ndrAccIRWad <br />Q <br />Nam <br />18. Dis repancy <br />taa Dlccrapsnq rnd:rana. Space ❑ Oue Ry ❑Typo ❑ Residue ❑ PrImal paged. ❑ FN RaledI1 <br />ill <br />Manifest Reference, Number; <br />18b.MkmatafaAAy la Generator)/ U.S. EPA ID Number <br />U <br />K <br />Fadbrs Phare. r <br />N y <br />18c. Slgw—Wi d lent Fa0,ly (or Gemara <br />19. Hsrardwa Wavle Repos Mermgement Meeyd Cedaa 0.e., code, for harardars wale treatment d�eP�% and recydMg ayslemR) <br />�t7 <br />Y3 <br />1 Z 3. 4. <br />20. Dealgnatd Farley 0vam m Opamtm C.,iftwgon d r"pt of hmmious nwaleh emvred by Na rnaMfeH MMM as nd.d M Item 15a g <br />11 n ams gne <br />ENE ATOR'S INITIAL COPY <br />EPA Fein 8700.221RV 3-94) rrayous ad one are euwnv. <br />