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SSL SK SHIP# 228758940 111111 111011 <br /> Please print or type. G 0 Form Approved.MB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.P e of R e P 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL0004446093 m 1' 0 S KS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(Wered than mailing address) <br /> Certified Tire 1630 <br /> 6028 Dougherty Rd <br /> DUBLIN CA 94568-0000 <br /> Generators Phone: 925-833-9700 <br /> 6.Trrop�.Qonlrynv.t9W SYSTEMS INC U.S.EPA ID Number TXROSOOS1205 <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 SAN JOSE U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE � CA 95133 <br /> 408-441-0962 CAD059494310 <br /> l 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 /> 1 NON—RCRA HAZARDOUS WASTE, SOLID DM P 223 <br /> o (OIL FILTERS) <br /> �is <br /> Z 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:SJ 80362485. TI23378 CSG: <br /> ���3a 319a'lol900 <br /> 24H EMERGENCY#800-468-1760-CH/SK/TFI-Contract ret iebyge erator confers aggen y authori y <br /> on°initial transporter to add or substitute additi nal trans orters on enerato s behalf. <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:thereby declare that the contents of this consignment are fully and @dcurately described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeledlptacarded,and siren all respects in proper condition for transport according to applicable InternationaE and national vvernmental 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 <br /> 1 certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)o if am a small quanti eneratar)is true. <br /> Gen Print yped Name Signatu Day Year <br /> .t c.lv IV L6 1 <br /> 16.Int nal Shipri is <br /> I- ❑Import to U.S. ❑Export from U.S. Port of en ?exit: <br /> ? Transporter signature(for exports only): Date leaving <br /> K 17.TransporterAckircWedgment of Receipt of Materials <br /> w <br /> T spo r 1 PrintedjTyped Name nature Month Day Year <br /> O <br /> a <br /> ZIrr 2 Prloteq[Typed Name uMoya' Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑QuantityTy <br /> ❑ pe ❑Residue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generetor) - U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone'. <br /> W 16c.Signature of Altemate 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 /> G 1. 2. 3. 4. <br /> 20.Designated Facility 0 neor Operator:Certification of receipt o rdous materials coveraliiby the manifest excepA noted in Item 1 <br /> PrinteciTyped Name - Signature Month Day Year <br /> Ll <br /> EPA 176817000-222In15,�61ZL Previous editions are osolete. DES IG TEDF ITYT EPA'se•MANIFESTSYSTEM <br /> 77 <br />