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SSL SK SHIP# 223069013 11111111111011111111111111111 <br /> 0 0 6 1 3 6 9 9 0 S K S <br /> Please print or type.(Form designed for use on elite(I2•pitch)typewriter.) Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2 Pa e 1 of 3 E ency Response Phone 4.ManiFest Tracking Number <br /> WASTE MANIFEST CAL000397036 1-800--468-1760 SKS <br /> 5 Generator's Name and Mailing Address Generator's Site Address(f different than mailing address) SKS <br /> Foodliner Foodliner <br /> PO BOX 55293 2467 E Mariposa Rd <br /> STOCKTON CA 95205-7893 <br /> Generator's Phone 209-642-5020 STOCKTON CA 95205-7893 <br /> 6.Transporter i Compan Na a U.S.EPA ID Number <br /> SAFETY-KLEYEN SYSTEMS INC TXR000081205 <br /> 7 Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENVIRONMENTAL SVC INC. MAD039322250 <br /> 8.Designated Facility Name and Sile Address CLEAN HARBORS GRASSY MOUNTAIN U.S.EPA ID Number <br /> 3 MILES EAST, 7 MILES NORTH KNOLLS EXIT 41, OFF I-80 <br /> KNOLLS , UT 84083 <br /> UTD991301748 <br /> 435-884-8915 <br /> Facility's Phone: <br /> ya 9b U S DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Conta hers 11.Total 12.Unit <br /> HM and Packing Group(K any)) No. Type Quantity M.Nol 13 Waste Codes <br /> 1M011ill NON RCRA HAZARDOUS WASTE SOLIDS, J DM ��� P 352 <br /> o (ABSbRBENTS CONTAMINATED WITH OIL), NFA ` - --;- --� - <br /> Z 2 i <br /> W <br /> 3. <br /> I j <br /> t <br /> 4, <br /> 14 Special Handling Instructions and Additional Information TSD:GM 74410232 F021051 CSG: <br /> 24 HR EMERGENCY #1-800-468-1760 (SK / TFI) 1--70 (-a 2S— <br /> qrFAuQrHMPNI <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 dassified,packaged. <br /> marked and labeled/placarded.and are in all respects in proper condition for transport according to applicable international 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 terms of the attached EPAAdmowledgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(it I am a large quantity generator)or(b)(if I am asTall quardity generator)is true. <br /> F <br /> neralor's/Offeroes PiintedfTyped Name �y Signature Month Day Year <br /> V,� X <br /> J International Shipments <br /> � ❑Import to U.S. Export from U.S. Pat of entry/exil <br /> Transporter signature(for exports only). Date leaving U S.: <br /> W 17.T Acknowledgment of Receipt of Materials <br /> T 1 Printedfiyped N Signature Month Day Year <br /> CL bZZ 19 iq 117 <br /> co:!�ped Name -�—'� Signabrre Month Day Year <br /> G� i �%t <br /> t- <br /> 18.Discrepancy <br /> 1 Ba.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Reject ❑Full Rejection <br /> Manifest Reference Number <br /> r <br /> l8b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> _J <br /> U <br /> u- Faolays Phone. <br /> W1&Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> X <br /> y19.HazardoufWaste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> � <br /> 1. � F. <br /> 3. 4. <br /> tUI <br /> 20.Designat acil Owner or Operator: rtification of receipt of hazardous materials covered by the man' except as rut n It 18a <br /> Pri, R arta y r <br /> EPA 8700- 2 e.3.05) Previous difionsareobsolete. l I NATED ILITYT DESTINATION STATE(IF REQUIRED) <br /> 1)7817805/1227158 <br />