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SSL SK SHIP# 230196726 1111111111111111111111 <br /> 0 0 7 2 7 6?4 1 6 K 3 <br /> Please print or type. Foran Approved.OMB No.2050-0039 <br /> UNIFORM!HAZARDOUS 1.Generator ID Number 2. ge o 3. mem R e Pip 4.Manifest Traekin Number <br /> WASTE MANIFEST CAL000361071 1—tsaa— � `"'g 0 0 7 2 6741 SKS <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Moe Auto Repair <br /> 2255 S Airport Way Attn: Moe <br /> STOCKTON CA 95206-3338 <br /> Generators Phone: 209-939-1490 <br /> s.Tr9WiiiprnpAnyt�1V Namo SYSTEMS INC U.S.EPA ID Number <br /> tSLTXR000081205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. 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 /> CAM9494310 <br /> 408-441-0962 <br /> Faulitys 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)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> oX 1 NA3077 HAZARDOUS WASTE SOLID, N.O.S. -$pF' P D0 D006 D007 <br /> , (LEAb, CHROMIUM), 9, b6 III <br /> 04- DM 181 <br /> z z. <br /> 3. <br /> 4. <br /> 14.Special Handling lnswctionsand Additional Information TSD.-SJ 81879011 MO 843 CSG: <br /> 1)ERG#171• � Q <br /> 24H Er4ERgNCY#m-468-1760-760 -Contract retai by gen rotor confers aggencZh y <br /> on initial trans orter to add or substitute ad ition tran or er on ene Eonr <br /> i6. GENERATOR'SIOFFEROR'SCERTIFICATION:Thereby declare that Me contents of this consignment are fully and accurately described above by the proper shipping name,and are dassfied,packaged, <br /> marked and Iabeledlplararded,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 Prim <br /> Exporter,I certify that the contents of fhis consignment conform to the terms of the attached EPA Acknowledgment of Consent. ary <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quanfity generator)or(b)(if I am a small quantity generator)is true. <br /> GeneratorslOfferor's PdMedlTyped Name Signature Month Day Year <br /> J <br /> _j16.Ince ational Shipments encs - <br /> i- ❑Import to LLS. Ll ifrom U.S. Pon of entry/exit: <br /> ? Transporter signature(for exports only)! Date leaving U.S.: - <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Tra rter 1 Printedfryp arae Signature Monts Da Year <br /> -7 1 <br /> Transpo r 2 Pd tedlTyped Name Signature Month <br /> Day Y ar <br /> J- <br /> IB. <br /> 1B.Discrepancy <br /> Ise.Discrepancy Indication Space ❑quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference <br /> 186.Alternate Facility(or Generator) Number: U.S.EPA ID Number <br /> J_ <br /> V <br /> LL Fadlity's Phone <br /> W 18a Signature ofAltemate Facility(or Generator) <br /> a ar Month Day Ye <br /> z <br /> as19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems)LAJ ` <br /> 0 1. 2. 3. <br /> 4. a <br /> 20.Designated Facility Own or Operator:Certification of receiptof haza materials covered by the manifest except sled in Item 1 <br /> 3eo Z/ <br /> Pnmecv Typed Name Signature <br /> �Tj MonthDa Year <br /> Ll"I rm 870027(R�ev112��)1 pious DESI ITY TO PA's e-MANIFEST SYSTEM <br /> 87646 B 95 Q <br /> Page 3 <br />