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SL_ , .. .SK SHIP# <br /> 2293-3q�t9 p g g <br /> Please print or type. Form Approved. 2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number �� r 2.Page 11 3.Eme�r�,g9g�n Rgs�eoonse Ph g 4.Manifest Tracking Number �( <br /> WASTE MANIFEST CA1.0001„Ar,._,1 1 1 tS `i�'S-1 # '�! 1007181976 n V 0 <br /> KS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) J <br /> D & D Lift Inc, <br /> ,:8.20 Rhonda Way <br /> TRACY CA 95304-1608 <br /> Generator's Phone: 12,09-229-7440 <br /> I.Tr�gVrtr I Cornpany-N�m(e 'STEMS INC - U.S.EPA ID Number <br /> Jt I TX{I�4�Ih0R?F'i�t5 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number 4- <br /> CLEAN HARBORS ENV SVC INC. I MAI)0 ,3 Sc2W 50 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS SAN ,LOSE U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE CA 95133 <br /> 408-441-096 <br /> Facility's Phone: GADO 5 94'31c 31 0 <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 /> 0 1 NON RCRA HAZARDOUS WASTE SOLIDS DM � � <br /> (DEBRIS, PETROLEUM HYDROCARbONS1 <br /> w <br /> w 2. NON--RCRA HAZARDOUS WASTE, SOLID C DM 1 b �, <br /> (OIL FILTERS) 297, <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:S T <br /> 80584541-3 DDO78;; CSCE; <br /> p� <br /> 24H EMERGENCY#800-468-1760-CH/SK/TFI-Contract retained by genera or confers a ency ar-tthori on initial, translont-ter to add 0 y <br /> substitute t , t r e � - <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 conditionfor 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 ter,ms of the attached 217AAcknowledgrnent of Consent. ' <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantityor)or(b)(if I am a smallarrUty generator)is true. <br /> enerator' is Nlltdqyrd Name naf <br /> - <br /> Month Day Year <br /> � 16.International Shipments � ❑ 16 I/q I <br /> ZImport to U.S. ❑Export from U.S. Port of entry/exit: <br /> Transporter signature(for exports only): Date lea*,g g U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials LU <br /> TrannspZortl jPri ted/1-yped Nam Pri ted/Typed Nam Signature <br /> O Month Day Year <br /> Ner 2 PrintedlTyped Name 10t / <br /> Si a Month Da Year <br /> F En n•titi N141 l <br /> 10 <br /> 18.Discrepancy Ito <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection J ❑Full Rejection <br /> 18b.Alternate Facility(or Generator) Manifest Reference Number: <br /> J <br /> U.S.EPA ID Number <br /> -- L Facilitys,Phone:- __ ---_ --- <br /> w 18c.Signature of Alternate Facility(or Generator) <br /> Q Month Day Year <br /> Z <br /> ti19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) y <br /> Lu 1 <br /> 2 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> P ed Name <br /> Month Da Year <br /> b <br /> EPA Form 22(Rev.�2-17) Prev use ibons are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br /> I N00512, . {P: 1.� #,.3 ac, - 75 1 2'1003 1 56-7 77 <br />