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SSL SK SHIP# 228113214 <br /> Please priplrdf type. Form Approved.OMB No.2050-0039 <br /> NIFORM HAZARDOuS 1.Generator ID Number 2.Page of 3. meryecy Respyse Ph 4.Manifest Tracking Number (� <br /> WASTE MANIFEST CAL000397036 —tS�fD-4[atl-1 l b0 00 <br /> ®�0 0027 (V K V <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Foodliner Inc Foodliner Inc <br /> PO Box 55293 2467 S. Mariposa Rd <br /> STOCKTON CA 95205-0000 <br /> Generator's Phone: 201-595-0280 STOCKTON CA 95205-0000 <br /> 6.TraspoFITYESLEEN SYSTEMS INC U.S.EPA ID Number TXROOOO81205 <br /> s <br /> 7.Transporter 2 CompanyNam U.S.EPA ID Number <br /> 6L-Cvri.j �,at�5 MPK'� 0-3M Z-.L-� <br /> 8.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 /> CAD059494310 <br /> 408-441-0962 <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(if any)) No. Type Quantity Wt.Nol, <br /> NON RCRA HAZARDOUS WASTE SOLIpp51 DM P 352 <br /> 0 (ABSbRBENTS CONTAMINATED WITH OIL), -IV* <br /> 2. NON—RCRA HAZARDOUS WASTE, SOLID DM I P 223 <br /> (OIL FILTERS) <br /> 3. <br /> 4. <br /> 14.Special Handling instructions and Additional Information TSD:SJ 79683567 x023114 CSG: ; <br /> 24H EMERGENCY#800-468-1760—CH/SK/1TFI—Contract retained by generator confers a envy authori y <br /> on initial transporter to add or substitute additional transpacters an aenerat h <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 Iabeledlplacarded;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 /> ce'fy that the waste min imiza'on state en t identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Grp(Ltr's/Cffierop am Signature Mont Day Year <br /> 16.International Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entrylexit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> 04 17,Transporter Acknowledgment of Receipt of MaterialsLU <br /> .. <br /> Tran o,r 1 Printed/ d'Name Signatu Mon Day Year <br /> V�A e L ! Io 19 <br /> N 2 P'ta�dLLypBd Name Sign Mon Day Year <br /> H <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> F 18b.Alternate Facili�(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> ra Facility's Phone: <br /> W 18c.Signature ofAftemate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 19.Hazardous Waste R poj M nagement Method Codes(i.e.,codes Pr hpzardous w ste treatment,disposal,and recycling systems) <br /> r <br /> C 1. 2. 3. 4. <br /> HH1 I <br /> 20.Designated Facility Owner or Opprator Certification of receipt of hazard materials covered by the manifest except as noted in Item l8a <br /> Prid p a Sig` re CN Mo Y <br /> I 'g ,r <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br /> 1)8019365/1530056 2)7612003/156777 <br /> i <br />