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1L SK SHIP# 227550567 <br /> Please print or type. Farm Approved.OMB No.2050-0039 <br /> Generator ID Number 2.Page 1 of 3. mer,Pcy Rqs a Phope _ 4,ManlfestTracking Number <br /> UNIFORM HAZARDOUS f'AI_RM0i2f R f3393�. 7 -�se/I,lt-r+ I r 9�Ic7 �( <br /> WASTE MANIFEST 00 b 9 J C-8 O 2 SKS <br /> 5 Generator's Name and Melling Address Generator's Site Address(if different than mailing address) <br /> JB Hunt - St uca <br /> 2650 Loomis Rd <br /> S T OCKTON Cid 95205-0000 <br /> Generators Phoney -��`�'y t <br /> 6.Tr�n��rE �rt '� ER SYSTEMS INS U.S.EPA ID Number TX R@00081205 <br /> 7 Transporter 2 Company Namce] q�1 -1m r'T1 F SVC <br /> a1i+ U.S.EPA ID Number 1� ry-y� �f <br /> �.L L'_I'T,� H ARY.k S ENVIR;OWMENTAL SVC illy. MAD039322250 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE U.S.EPA ID Number <br /> 1021 BFRRYE5SA ROAD <br /> SAN JOSE CA 9:11.33 <br /> CAD059494310 <br /> 406--441--096 <br /> Facility's Phone: <br /> gam 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> Hpe M and Backing Grnup(if any)) No. TyQuantity Wl,Nlo13.Waste Codes <br /> 1NONE LEON RCRA 1 WZ�a4�I 0]B, WASTE SOLIDS, � �ltYi 7 <br /> o R►�S�1�tBENTS CONTAMINATED WITH i0A <br /> w <br /> LU 2 NON-111 HAZARDf11_iS WASTE, SOL Ila � DM C.23 <br /> (OIL FIL TEW) <br /> 3. <br /> 4 <br /> 14.special Handling InsrruCtions and Adcl tlonal Information TSrt.-5.T 79000100 TB9793 CSL <br /> 24H EMERGENCY#8@@-41t7li/N/TFI-Con t acts retained by generator con Fell agiii authori y <br /> on initial t fi 't ' ►' s r - , ., � <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 labeledlplacarded.and are in all respects in proper condition for transport according to applicable international and natioral governmental regidations.If export shipment and I am the Pdmary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the Attached EPAAcknowledgmerit 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(bs(if I am a small quantity generator)is true. <br /> Generator;sOfferor's PriniedfTyped Name Signature Month Ray Year <br /> _j 1 16.International Shipments <br /> i ❑Impart to U.S. ❑Export from U.S. Pori of ertrylexit: <br /> z Transporter signature(for exports cniy) Date leaving U.S.: <br /> W 17.Transporter Acknowledgment ofRecall orMaterials <br /> W <br /> I- Tr rler 1 PrinledlTyped Na a Signatur rf i ,til - Month Day Year <br /> rZ ,nt ( + J', <br /> Z Transporter 2 Printed(fyped Name Signal a L' M nth Day Year <br /> a <br /> a <br /> 18.Discrepancy <br /> 18a-Discrepancy Indlr9on Space ❑ Quantity Ll Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generators U.S.EPA ID Number <br /> J_ <br /> U <br /> Facility's Phone: <br /> LU 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> rn19.Hazardous Waste Report Management Method Codes(i.e..codes for hazardous waste treatment.disposal.and recycling systems) <br /> Lu 1. 2. 3. 4, <br /> 0 <br /> 20.Designated Facility Owner or Operator CerGTicalion of receipt of hazardous materials covered by the marnfesl except as noted in Item 18a <br /> Printed ped Name Signature Month Day Year <br /> EPA Form 87101k0-22(Rev.1Q2.17)_Pretviouseditio/ns are1obsolete. GENERATOR'S INITIAL COPY <br />