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SSL SK SHIP#-228591790 <br /> Please print or type. 0 0 Form Approved OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number CAL 4253G3 2.Pa g�f 3.Erne �y Rgsgppge P 7 , 4.Manifest Tracking Number SKS WASTE MANIFEST 1 10—+Fbti 1!t� 0 0 6 9 6 016 2 V KS <br /> 5.Generators Name and Mailing Address Generator's Site Address(d different than mailing address) <br /> Gardner Trucking/Classic Sales In <br /> 2577 W Yosemite Ave <br /> MANTECA CA 95337-9641 <br /> Generators Phone: 209-249-3204 <br /> s'Tr 3 SYSTEMS INC U.S.EPA ID Number 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 Site 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 /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(f any)) No. Type Quantity Wt.Nol. <br /> X 1. ! tyr{ P <br /> O !�' <br /> w <br /> /v.v.s �-lCL/9CzD�igi <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:GM 80183380 GA15065 CSG: <br /> i)ERG#154• _ A <br /> 24H EMERG&CY#800-468-1760—CH/SK/TFI—Contract retained by generator confers agency authority <br /> an <br /> 15. GENERATOR'S/OFFEROWS 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 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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(f I am a large quantity generator)or(b)(if i am a small quantity generator)is true. <br /> Goneretoes/Offerors Printedfryped Name Signature Month Day Year <br /> 6 19 <br /> 16 Intemational:Shipments <br /> ❑Import m U.S. ❑Expo U.S. Port ofentry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> OC W 17.Transporter Acknowledgment of Receipt of Materials <br /> Trarrter 1 P tedfryped Nam( Sign Month Day Year <br /> C) <br /> 0(bloll r <br /> rn Trarter2l;Ant�(rypedName Mo Day Year <br /> 1 . screpancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type Jyj Z�r/,�❑Residue ❑ lartiai Rejection ❑Full Rejection <br /> AN30119Oa/Rest Rele eNumber. -7-10-29'C% <br /> 18b. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> V <br /> ra+. Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> C 1. 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a C ,y <br /> Printedfryped Name Signature Month Day Year <br /> G <br /> EPA Fo 0 R'-2 iffv.12-17) PreViousWitions are obsolete. DESIG A D PAGILITY TO EPA's e-MANIFEST SYS EM <br /> 1) -1873/8( <br />