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SK SHIFB <br /> Please pont or type (Form designed forum onolite(.2-pito. -dawdler.) Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2 P of 3. R 4.difns 519 693 <br /> SKS <br /> UNIFORM HAZARDOUS CAL000405390 � �1 �#` '-�,°��'qY.'-.2� � '(41`r.1} °� `lig (01J <br /> WASTE MANIFEST <br /> S.GB@0amitofs Naame d Mellingpddrfles Geneatofs Site Address(if different than mailing address) <br /> ldlesel Ulrect West Inc _ <br /> 3651 Duck Creek Dr PO Box 3109E <br /> STOCKTON CA 95215-7956d d. 1�� Lie <br /> Genaratofs Phone: 916-857-1000 <br /> 6.Tr5"EkF'WfiS°V&TY SYSTEMS, INC. JAN 06 2010 U.S.EPA ID Number TXR0000612V <br /> 7.Transporter 2 Company Name j >G,f,EPAIDNumber <br /> T t� ' <br /> 8.Designated Facility Name and Site Address --CLEAN HARBORS SAN JO% 'LLC - U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> SAN 305E , CA 95133 <br /> 406-441-0962 CAD059494310 <br /> Facility's Phone: <br /> gra 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Pecking Group(d any)) No. Type Quantity Wt.Nol. <br /> N014 RCRA HAZARDOUS WASTE SLIDS, DM <br /> a (USE OIL AND ABSORBENTS), N/A <br /> - / <br /> c <br /> z 2. <br /> W <br /> c9 <br /> 1 <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSDtSJJ <br /> 24 HR EMERGENCY #1--60N-468-1760 (SK ! TFI) ti '50 50 19 aq S <br /> AUTH AS "AGENT=FOR" BY GEN TO RETAIN LICENSED SUB CARRIERS AS NECESSARY <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 labeledlplacarded,and am in all respects in proper condition for transport according to applicable intemartonaland national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I cerfify that the contents of this consignment conform to the terms of the attached EPAAcknowledgmenl of Consent. <br /> I cal that the waste minimization statement identified in 40 CFR 262.27(x)(if I am a large quantity generator)or(b)(If I am a small quantity generator)is We. <br /> Gener fslOff r. Prin ed Name Sig re Month Day Year <br /> o 9 zs !y <br /> 16.International fthipments <br /> p— ❑Import to U.S. ❑Export horn U.S. Port of entrylexh: <br /> Transporter signature(for exports only): Date.leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials - <br /> Transporter l Pnntedrryped Na Sign �,. Month Day Year <br /> z Transporter 2 Pnnlednyped Name Signs Month Day Year <br /> 6 <br /> K <br /> H <br /> } 18.Discrepancy <br /> 18a.Discrepancy Indication Space ElQuantity ❑Type ❑Residue ❑PaNal ReJection L1Full Rejection <br /> Manifest Reference Number: <br /> 18b.ARemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> u Facilitys Phone'. <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. ,{/ � 2. 3, 4. <br /> 20.Designated Facility Oweror Operator.Certification of receipt M ha undous materials covered by the manifest except as n ih Item las <br /> PrintedrTyped N Signature MonthDay Year <br /> EPA F e" ;�Wiouseditions are obsolete. DESIGNAT ACILITYTC GE*'FRAiOR <br />