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_ ,sL �.f7,/.7 <br /> SK SHIP# F'I'TS 0055238691Ks <br /> Pleaw print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-N39 <br /> UNIFORM HAZARDOUS 1.Generator ID Number' 2.Page 1 of 3.Emergency Response Phone 14.Manifest Tracking Number <br /> WASTE MANIFEST CALF 0O2s 54 1-800-46$-1760 0 5 5 2 3 8 6 9 SKS <br /> 5.Generator's Name and Mailing Address Generators SiteAddmss(if different than mailing address) <br /> Lodi Honda <br /> 1700 S Cherokee Lrl <br /> LODI CA 95240-7808 <br /> Generators Phone: .559-443-5427 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> SAFETY-KLEEN SYSTEMS, INC, TXR000081205 <br /> 7,Transporter 2 Co ny Name „U.S.EPA ID Number TT <br /> &) <br /> B.Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE U,S.EPA ID Number <br /> 1021 SERRYESSA ROAD <br /> SAN .JOSE , CA 95133. . <br /> !x18-441-0962 CAD059434310 <br /> Facility's Phone: <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 17:Total 12.Unit <br /> Group HM and Packing (if any)) 13.Waste Codes <br /> No. Type Quante wtivd. <br /> ac X 1. NA3077 HAZARDOUS WASTE SOLID, N.O.S. I D� D005 D0t07 D008 <br /> 0 , (CHROMIUM, LEAD), 9, �G III l l7tJ <br /> 141 <br /> w X 2 <br /> 3. <br /> 4. <br /> 14.Spedal Handling instructions and Additional Infoma5on a <br /> TSD:S:I 71413663 L024049 CSG: <br /> 1lEHR EM1 GENLG#128• <br /> 24 HR EMEf�GEP!CY #1-A00-468-17613 (SK ! TFI) t J <br /> 01 JTW r 11r r”- fV Sti To R1-T64i__Tr ;: rc;:n tzt f [1T7AT �Iy—eta �fE��SSiIRY <br /> 15. GENERATOR'SWFEROR'S CEFMFiCATtON:I hereby deWare that the contends of this con.gnmentare fully and accurately described above by the proper shipping name,and are dassified,packaged, <br /> marled and labeled/placarded,and are in all respeg-ts in proper condition for transport according to applicable intemational and national governmental regulations.ff export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform the terms of the attached EPAAcknowledgmentof 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)(ifl am a small quarpty generator)is true. <br /> Gtors/ ro s Prin Name Signature Month Day Year <br /> 16.Intema'onal Shipments � -3 , 7 <br /> ZImport to U.S. ❑Export Froin U.S. , - Port of eniryJexit: <br /> Transporter signature(for exports only): Date leaAng U.S.:;. <br /> U 17.Transporter AdmowladgmeMofReceipt ofMaterials . <br /> IX Traer 1 PdntedR Name Signature' <br /> ignature Month Day Year <br /> a <br /> Q <br /> Transport S <br /> lfy Nage JJ Sig natu Month Day Year <br /> ,,/) .,. <br /> 16.Discrepancy <br /> 4Z 2142- <br /> 18a.Discrepancy Indication Space ❑ 11''y <br /> Quantity ❑Type- El . !_-i'Parti� ejection ❑Full Rejection <br /> Manifest Reference Number. <br /> 181b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> _J <br /> Q <br /> LL Facility's Phone: <br /> U.1 18c,Signature of Alternate Facility(w Generator} Month Day year <br /> Z <br /> y19.Hazardous Waste Report Management thud Car'w(1.e,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LLI G 1. 2. 3. 4. <br /> 20.Designated Facility Owner or pomtor:Certification of receipt of hazardous mater s covered by the manifests s t <br /> 00 P' edRyp aims Signal Month Day Year <br /> t � G <br /> -E#eA Form-8700=22 Rev.M5=Previoweditions-are a <br /> ) EYESfGNQTP6':FAC1qfYTO-ffEST[fJATtOTI STATE(fF REQl11F?ED) <br /> 1)7572'239/344499 _ <br />