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SSL SK SHIP# 225781298 <br />Please print or type. (Form designed for use on elite (12 -Ditch) tvoewriter.l <br />Fnrn Annrnvpri nMR Nn ?0rn_nnsQ <br />EPAForm 8700-22 <br />834201 tRe 166L003 Previous editions are obs�e. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />UNIFORM HAZARDOUS <br />1 Generator ID Number CAL000420023 <br />2. Pagel of <br />3 Emejgq�njy R� P}tg� <br />1j tS10ffC�t 1 �b <br />4. Manifest Tracking Number <br />WASTE MANIFEST <br />011559094 FLE <br />5 Generator's Name and Mailing Address Generator's Site Address (if different than madmg address) <br />Stockton Delta Resort <br />14900 W Highway .12 <br />LODI CA 95242-0000 <br />Generators Phone, 209-283-1589 <br />'94 T' Y E R SYSTEMS INC US EPA ID Number TX ROOOO81205 <br />7 Transporter 2 Company Name U.S. EPA 10 Number <br />CLEAN HARBORS ENVIRONMENTAL SVC INC. MAD039322250 <br />6. Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE U.S. EPA ID Number <br />1021 BERRYESSA ROAD <br />SAN JOSE , CA 95133 <br />408-441-0962 CAD059494310 <br />Facht 's Phone: <br />9a <br />9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br />10 Containers <br />11. Tota <br />12 Unit <br />HM <br />and Packing Group (if any)) <br />Quantity <br />Wt.Nol. <br />13 Waste Codes <br />No <br />Type <br />NON RCRA HAZARDOUS WASTE SOLIDS <br />DM <br />P <br />223 <br />e <br />(DEBRIS, PETROLEUM HYDROCARBONS; <br />w <br />Z <br />2 <br />LU <br />.4- <br />3 <br />� <br />4. <br />14 Special Handling Instructions and Additional Information TSD : SJ 77204842 ST43054 CSG: <br />24 HR EMERGENCY #1-800-468-1760 (CH / SK / TFI) �)1 <br />AUTH AS "A N Y GEN TO RETAIN LICENSED SUB CARRIERS AS NFCF-C;SARY <br />1; GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby dedare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged. <br />marked and labelediplacarded. and are in all respects in proper condition for transport according to applicable intemational 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 EPAAcknowledgment of Consent. <br />I certify Ale waste inimization statement identified in 40 CFR 262.27(a) (B I am a large quantity generator) or (b) (if I am a small quantity generator) is true. <br />neralor rots Pn y ame signature on ay Year <br />!— <br />16 Int ational Shipments <br />❑ Import to U.S. ❑ Export from U.S. Pat of entry/exit <br />Z <br />Transporter signature for exports only): Date leaving U.S.: <br />IX LU <br />17 Transporter Acknowledgment of Receipt of Materials <br />� <br />T er 1 Printed? ame alk ay earn <br />aI <br />// <br />Cp / <br />rn <br />Z <br />Transporter 2 Pnn iTy meignalure on ay Year <br />4�7 z4 <br />I Its <br />18 Discrepancy <br />18a Discrepancy Indication Space El Quantity El Type El Residue n 1:1 Full Rejection <br />R <br />Manifest Reference Number. PivF;D <br />1?b Alternate Facility (or Generator) U S. EPA ID Number <br />J <br />a <br />AUG 0 9 2018 <br />� <br />Facility's Phone: <br />w <br />18c. Signature of Alternate Facility (or Generator) Month Day Year <br />Z <br />ENVIRGINMENT,41 11 Ir- .1 <br />U, <br />19, Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br />0 <br />1 j <br />2 <br />3 <br />InFITMtN <br />20. Designated Fac,wir P mer rata: emficqw ofreppy9hazardous materials covered by the mardfesl ed in Item 18a <br />ritedlfyped Name SignaN <br />ally I <br />I <br />EPAForm 8700-22 <br />834201 tRe 166L003 Previous editions are obs�e. DESIGNATED FACILITY TO DESTINATION STATE (IF REQUIRED) <br />