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SSL SK SHIP#. @9:A 97q ' 111111111111111111111111111111111111111 <br /> 0055212025KS <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMS No.2050-0039 <br /> UNIFORM HAZARDOUS= 2,Pag 1 of 3 E r e cy a nse P 4.Manifest Tracking Number SKS WASTE MANIFESTCAD9819676H0 1"���-�F6 -1�°g� 005521202 SKS <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Stockton Dodge <br /> 3333 Auto Center Cir <br /> STOCKTON CR 95212-2837 <br /> Generators Phone: 441-000-3000 <br /> 6.LppgggCIJ.DoplgartyN"SYSTEMS, INC. U.S.EPA ID Number TXR000081205 <br /> 7.Transporter 22 CompanyNameU.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS SRN JOSE U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE , CA 95133 <br /> CRD059494310 <br /> 408-441-0962 <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> 13.Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity WLNoI. <br /> z X 1 UN1268, WASTE PETROLEUM DISTILLATES, 0 DM eP D001 D008 018 <br /> o N.0.5. , 3, PG II ( 213 <br /> Z 2. <br /> W <br /> U• - <br /> 4. <br /> —T— <br /> _—._ <br /> 14.Special Handling Instructions and Additional Information TSD:SJ 71140167 ST37139 /5,6,:,-, <br /> 1)ERS#128 �"�a <br /> 24 HR EMEI&SENCY 01-800-468-1760 (SK 1 TFI) <br /> AUTH AS "AGENT—FOR" BY GEN TO RETAIN LICENSED SUB CAR AIRY <br /> 15. GENERATOR'SIOFFEROWS CERTIFICATION: I hereby declare that the contents of this consignment are Polly 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 intemabonal 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 gen r)or( I am a small quantity g or)is t <br /> r s10 rots Primed Name Si a e Month D Y, <br /> 16.Interinonal Shipments Import 10 U.S. ❑Export from Pan of entry le I <br /> r <br /> Transporter signature(for exports only): Date leaving .S.' <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> T .sp er 1 PrintedlTyp ame Signature M n Day Y ar <br /> N �� <br /> Transport 2Pd e111yped Name Signature Month Day Year <br /> K <br /> r <br /> 16.Discrepancy <br /> i 16a.Discrepancy Indication Space ❑ Quantityy j j <br /> ❑T pe Residue Partial Rejection El Full Re ection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> ua. Facility's Phone: <br /> w 16c.Signature of Alternate Facility(or Generator) Month Day Year <br /> r <br /> a <br /> Z <br /> S2 19.Hazardous Waste Report Managem nl M Mod Codes(i.e.,codes for hazallous waste treatment,disposal,and recycling systems) <br /> 1 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest exce as noted in tWn 1 <br /> 11I Pn d(Typed ame Signatu Mon h Day Year <br /> L <br /> EPA Form 8700-22(Rev.3-05) Previous dniions areob te. ESIGNATED CILITY ODES INATIONSTATE(IFREQUIRED) <br /> 1)7841976/1247752 <br />