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SSL SK SHIP# 225372757 <br /> Please print or .(Form designed for use or.elite(121kch)typewriter.) C 0 IF!rm Approve6d.OMS No 205M039 <br /> UNIFORM HAZARDOUS 1 Generabr ID Number 2.Page 1 of 3.Fmergency Response Phone 4.IllTmckle2g Number <br /> WASTE MANIFEST CAL000025654 1 1-800-468-1760 !f <br /> 0364 SKS <br /> S.Gerabr's Name and 0066 <br /> eng Address Genefab�s Site Address(ifdifrerent than matting adrtress) <br /> Lodi Honda <br /> 1700 S Cherokee Ln <br /> LODI CA 95240-780 <br /> Generator'sPhone: 21b9--, 40-8608 <br /> 6.7rensp 1 Company Name U.S.EPA 10%mtar <br /> SAF ..ETY-KLEEN SYSTEMS INC TXR000081205 <br /> 7.Tmnsporter2 Company Name <br /> U.S.EPA1D Nru^.her <br /> CLEAN HARBORS ENVIRONMENTAL SVC INC. MAD039322250 <br /> B.Designated Facility Name end Ste Address CLEAN HARBORS SAN JOSE U.S.EP'10 NurNur.&r _ <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE , CA 95133 <br /> Fadfitys Phare: 408-441-0362 CAD059494310 <br /> ga. 9b.U.S.DOT Desaiption(Including Proper Shipping Name,Hazard Class,ID Number, to.Conteiners it.Total 12.Unit <br /> HM and Packing Group Cf any)) _ n No. Type ovantfy 4VtNoL '13.'Nasie Codas <br /> X 1. NA3077 HAZARDOUS WASTE SOLID, N.O.S. P D$0 D00 D�0 <br /> (CHRbmium, LEAD), 9, bG III (D M <br /> w 2 _� 141 <br /> 3, <br /> 4 <br /> 14.Special Handling lnsmudionsand Additional lr.conation TSD-SJ 76466788 L024049 + '\ �CSG- <br /> I) ' <br /> 24E171HR#EMEfGENCY #1-800-468=17Yo 60 (CH / SK / TFI) tc �L+A <br /> SAQ l---- <br /> 15. GFJaERATOR'SlOFFEROR'S CER7IFICA.N:I hereby declare that 11 the wmeMs of this consignment arafuYy and arariaiely desaibeil above bythe'pmpar,*,ipping.ta;ne,and are classified,packageC. <br /> marked and Iabele0acaNed,and are in all respects in proper condition for transport affording to applicable international and national govemmental regulafio�s,f aspaf.sliprnent and I am the Primary <br /> Exporter,I certify that the cont.vs d(his consignment conform to the terms of the attached EPAAckrwwtedgmenl of Co sent <br /> I certify drat the waste mnVsi o,,n slafemendidentified in 40 CFR 262.27(a)(ifI am a large quantlty ganerabr)or(b I am a s quantitygenerabr)is We. <br /> Generato 0 es Pa'to yped Name Signature �"� •�• Mont Oa Y <br /> 11 e� <br /> J 16.Intemabonal Shipments ^ —^--- r <br /> i— `1 Import to U.S. ❑Export from U.S. _.._PoA of entrylexid <br /> Z Transporter silmadre(fo exports only): Date leaving U.S.: - -- <br /> - —� <br /> W 17.TrensponerAcknaNedgmeztol Receipt of Matsrials <br /> Tran r PrintedrT ._ Signet— _ Momh Day 1`ear <br /> 1K <br /> Z Transpo thin d7Typed Name Si ature <br /> Month Day Year <br /> C <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space v ��ii •11��'''�1 Z' <br /> Quantity -LJ Type '� -❑Residue� °�Partial Rejarlion t—�Full Roisciicn <br /> 186,Alternate Facility(or Generator) Manifest Reference Number, <br /> .. ... - U.S EPA ID Number <br /> J <br /> U <br /> Facillrys - <br /> w 18a Signattre ofAltemate Facility(or Gener3tor) <br /> Month Day 'fear, <br /> Q <br /> 2 <br /> y19.Hazardous Waste eporl Manage n''Me6(,a Codes(i.e.,codes for hazardous waste Ire tenant disposal,and recycling systems). —•� <br /> 3. <br /> A. <br /> 20.Designated Facility r o Operator.Call ofreQ of hazanlous materials covered by the manifest eyke as ed to Hem.18a <br /> Pdntedltyped Name $ignaWre M e <br /> � ) . ,,K- <br /> EPAFom8700.22(Rev. Prevoused'onsare e. DE GNATEDFACILITYTOGE `INATIGTdSTATE(IFlREQLIlED) <br /> 1)7572239/944499 <br />