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SK SHIP# 230827943 <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUSJT7�� <br /> DNumber 2.Page of 3. mer Re e P e 4.Manifest Tracking Number SKS WASTE MANIFEST <br /> CAI..O0(a4ti68T3. � FT.-r���-��t�-�°�:�+d S1�a7 <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> in e l FreiAhtlirtPs 1.-LC <br /> 1 POO S. McKinley Ave <br /> LATHROP CA 953;M-..0000 <br /> Generator's Phone: <br /> 6.Tran 'SYSTEMS TNr U.S.EPA ID Number TXR000081205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> GLEAM HARBORS ENV 399 INC. M,4D039,122250 <br /> 8.Designated Facility Name and Site Address (A E:AN HARBORS SAN OSE U.S.EPA ID Number <br /> 1021 BE:RRYESSA ROADSTAN JOSE CA 95133 <br /> 408—441•�-$96 CAD05-9494;31 tb <br /> Facility's Phone: <br /> 9a, 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)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> "WIDNEV NLN RrRA NAMRMUtS WASTE tf7!_.iltS, ;,: <br /> o (Olt. DIRT AND SAND), B4 <br /> ag <br /> z 2. i <br /> LU <br /> C9 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information Tt D,,S J 82540164 fl-146346 [;S(3 <br /> 244 } RGENCYAP,0th-468-1760-CH,'SK/71—CDntrict retained by generator, confers agency authori ;y <br /> on initial trans +ort:Nr to add or substitute additional trams tar,ters on enerator' s behalf. <br /> 15. GENERATOR'S/OFFEROR'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 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 EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement 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 /> GeneraW/Offeror's Printed/Typed Name Signature Month Day Year <br /> J 16.International Shipments <br /> 1:1 Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> LLI <br /> Trapsportef 1 Printed/Typed Name Signature Month Day Year <br /> CL <br /> Tra er2 rinted/TypeTName Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ 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 /> U <br /> Facility's Phone: <br /> UOj 18c.Signature ofAltemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLI G 1. 2 3. q. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed/Typed Name Signature Month Day Year <br /> EPA Form 8700-22Rev.12-17 Previous editions are obsolete. <br /> 1)13811 i7f iR!198944 GENERATOR'S INITIAL COPY <br />