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SSL SK SHIP# `;��J 1111111111111 ) 1111111111111111 <br /> Vy006391926SKS <br /> Please print or type.(Form designed for use on elite(12-pitch)tpewriter.) Form Approved.OMB No,2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number CAL000392478 2. ageof 3.�1 � �� � 1eT60 4.Manifest n Number <br /> WASTE MANIFEST O O 1926 SKS <br /> 5.G"ss bang and WilirlgAddreSs Generators Site Address(if different than mailing address) <br /> 1440 E Harding Way <br /> STOCKTON CA 95205-3104 <br /> Generators Phone: 972--555--1247 <br /> 6.Tr:P0"tET RF—y�Lffl SYSTEMS INC U.S.EPA ID Number TX R000081205 <br /> 7.TTENcoMR9 8 ENVIRONMENTAL SVC INC. U.S.EPA ID Number MAD039322250 <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 <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> t — SOLIDDM P <br /> o BSORBENT AND OIL), iVf�f ' ' � 1510 1 <br /> 81UJ <br /> 2. <br /> 3. t <br /> t <br /> Is <br /> 4. <br /> 14.Special Handling Instructions and Additional Information 151):5J 1Ve%J 413 4 <br /> 24H EMERGENCY#800-468-1760-CH/SK/TFI-Contract ret �. <br /> acne y genera cone envy aut i y <br /> on initial transporter to add or substitute additional spar <br /> on genera or' s behalf, <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 labeled/placarded,and are in all respects in proper condition for transport according to applicable international and�ovemmentafllons.If export shipment and I am iha Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowled nt en.I certify that the waste minimization statement Identified in 40 CFR 262.27(a)(iii am a large quantity gengrat ) e. <br /> Genera rs! r dnTV S natur Mo th Day Year <br /> J 16.International Shipments <br /> z ❑Import to U.S. ❑Export from U.S. o <br /> Transporter signature(forexports only): at vi S.: <br /> 17.TransporterAcknowledgment of Receipt of Materials <br /> WTranPer 1Printed/T ame Signature Month Day Year <br /> IL <br /> vu /7 9 <br /> 4 sp �r 22 P' tekTyped Name <br /> Signal Month Day Y <br /> 18. iscrepancy <br /> 18a.Discrepancy Indication Space El Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> W Facility's Phone: <br /> LU 18c.Signature ofAitemate Facility(or Generator) Month Day Year <br /> 5 —7 <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1• / <br /> 20.Designated acili Own or pastor:Certification of receipt of hazqW materials covered the manifest except a600tedl in I <br /> Pnnted/Type ame Signature Month Day Year <br /> EPA F)lgff ($jv43 t �p� v[o1Js editions are obsolete. SIGN D FACT Y TO TINATION STA E(IF REQUIRED) <br />