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5S` SK SHIP# 2229096507 _ <br /> Please print or type . <br /> UNIFORM HAZARDOUS 1 . Generator ID Number ., Form Approved . OMB No . 2050-0039 <br /> WASTE MANIFEST CAL000435028 2. Page 1 of 3 , me R s o se Ph 4. Manifest Tracking Number <br /> 1 -�� = g�- 1 � i0 SKS <br /> 5. Generator's Nam and Mailing Address07181311 <br /> j <br /> Tires I1 r e C Generators Site Address (if different than mailing address) <br /> t+ 221 North Wilson Way <br /> I STOCKTON CA 95205-0000 <br /> i Generator's Phone: 916-690-7010 <br /> s. Tr�Sp9lteTY mKpL�EN SYSTEMS INC <br /> �F E U .S. EPA ID Number <br /> 7 . Transporter 2 Company Name TX R000081205 <br /> CLEAN HARBORS ENV SVC INC . U .S. EPA ID Number , <br /> 8. Designated Facility Name and Site Address <br /> MAD039322250 <br /> THERMO FLUIDS INC U .S . EPA ID Number <br /> 12533 BE CARPENTER DR <br /> 503-788 - 4616 CLACKAMAS , OR 97015-8988 <br /> Facility's Phone: OR0000025197 <br /> 9a. 9b. U .S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, <br /> HM and Packing Group (if any)) 10. Containers 11 . Total 2. Unit <br /> No. Type Quantity Wit./Vol, <br /> 13. Waste Codes <br /> 0 1 ' NON- RCRA HAZARDOUS WASTE SOLID <br /> ( DRAINED / UNDRAINED USED 6IL FILTERS ) DM p 223 <br /> Z 2 . <br /> c7 <br /> 3. <br /> 4 . <br /> 14. Special Handling Instructions and Additional Info motion TSD ; TPO 80724484 T 123022 a 5 � <br /> I <br /> 24H EMERGENCY#800-468 - 1760-CH / SK / TFI -Contract retained by generator confers aency authori y <br /> i r` r, { <br /> 15. GENERATOR'S/OFFEROR'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 condition for 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 terms of the attached EPA Acknowledgment 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 (b) (if I am a small quantity generator) is true. <br /> Generators/Offeroes Printed/Typed Name Signature Month Day Year <br /> So <br /> i 16. nternational Shipments <br /> F- ❑ Import to U .S. ❑ Exportfrom S. Port of entry/exit: } <br /> ? Transporter signature (for exports only): IIIII_ Date leav' g U.&. <br /> I= 17. Transporter Ptcknowledgm t of Receipt of Mat ` Is /11 tv <br /> Transpose <br /> ited/Typed Na Signature Month Day Year <br /> TLaaspodeN r 2 Priyped Name Signal <br /> o Month Day /Year <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space ❑ Quantity ❑ Type ❑ Residue <br /> ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> 18b. Alternate Facility (or Generator) U .S. EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> Fw- 18c. Signature of Alternatfp <br /> rator) Month Day Year <br /> a <br /> z <br /> 19. Hazardous Waste ReMethod Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) <br /> 1 . + 2. 3. 4. <br /> y <br /> 20. Designated Facility Oertification of receipt of hazardous materials covered by the ma lest exc t a de tem 18a <br /> Printedfr ame gnature Mo Day Year <br /> ( II ✓EPI )7872676%15603ditions are obsolete. DESIGNATED FACILITY TO GENERATOR <br />