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SSL SK SHIP#1229LZ75W�� ��IIIIII�IIII��II����III�I���I�IIIII� <br /> C 0 0 6 1 3 6 0 9 9 5 K S <br /> Please print or type.(Form designed for use on elite(I 2-pi typewriter.) Form Approved,DMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1-Generator ID Number Q Ob�. 2.Pae 1 of 3,Emer ency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST 1-8P�0 46$-1760 1006136099 SKS <br /> .Generators Name and Mailing Address pJ .L Generators Site Address(if different than mailing address( <br /> IS a pc m� lgey ebl'of <br /> lVl� <br /> �<3cr 0 R I a` a <br /> STOCKTONpr CA 95219-8703 <br /> enerator's Phone: 2a ( — `� <br /> 6.Trans iter 1 Com an NaUS,EPA ID Number <br /> SAFETY-OWEENme SYSTEMS INC TXR000081205 <br /> 7 Transporter 2 Company Name US.EPA ID Number <br /> CLEAN HARBORS ENVIRONMENTAL SVC INC, MADID39322250 <br /> B,Designated Facility Name and Site Address CLEAN HARBORS ENVIRONMENTAL SERVICES, IN U.S.EPA ID Number <br /> 2247 S HIGHWAY 71 <br /> KIMBALL , NE 69145 <br /> NED981723513 <br /> 308-235--4012 <br /> Facility's Phone. <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Conlainers 11,Total 2 Unit <br /> H1:1 and Packing Group(if any)) No Tvpe Quantity Wl.lVot 13.Waste Codes <br /> 01� X t.UN1268, WASTE PETROLEUM DISTILLATES, DM �/� P D001 l Does b018 <br /> 213 <br /> o N.D.S. , 3, PG II V ----. - <br /> - -- <br /> Uj <br /> z <br /> W <br /> c� <br /> 3 <br /> 4 <br /> 14-Special Handling Instructions and Additional Information TSD:N PP gip }. <br /> 1_ CS)G <br /> 1)ERG#128• ' <br /> 24 HR EMERGENCY #1-800-468-1760 (SK I TFI) X34`jq �v AS MFrEF; l�l� <br /> AUTH Ac; "ArFNT <br /> rr ;rniB- c/ <br /> 15 GENERATOR'SIOFFEROR'S CERTIFICATfON: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are class packaged. <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I ar the Primary <br /> Exporter.I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator(cr b((if)am a small quantity generator)is true. <br /> Signa?re Month Da Year <br /> 16-Intemational Shipments {1J� <br /> ❑Import to U.S. ❑Export from US. Part of entry! <br /> ? Transporter signature(for exports only): --- — <br /> Date leaving U S. <br /> w 17.Transporler Acknowledgment of Receipt of Materials <br /> a s er 1 PrintadlType ame <br /> O <br /> Signature 9 Month nDay Year <br /> CTransporter Pon Ryped a Signature <br /> onih Day Year <br /> 18.discrepancy Z <br /> 18a.Discrepancy Indication Space <br /> ❑ `' r°t` ❑TYW ❑Residue ❑Partial Rejection <br /> 1 ❑Full Rejection <br /> H 18b.Alternate Facility(or Generator) Manifest Reference Number <br /> `r U.S.EPA 1D Number <br /> U <br /> Facility's Phone: <br /> 0 nature Of Facility Q 18c 5i 9 ty(orGenerator) Month Day Year <br /> w19.Hazardous Waste Report Management Method Codes(i.e„codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 2- <br /> 20.Designated Facility Owner or Operator:Certirication of receipt of hazardous materials covered by the manifest except as n d in item 18a <br /> Phil Name J Signature <br /> Ln , f��1R�� Month Day Year <br /> EPA Form 8700-22{Rev.3-05revious editions are obsolete. ) t� rz <br /> , <br /> 07666541/1067A3 " ,.a ED FAC! ITY O DESTINATION STATE (IIF REQUIRED) <br />