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.!:�R9 alk 11111111 1111111 <br /> SSL SK SHIP# 219W977 0 0 5 5 2 1 2 0 2 S K S <br /> Please print or type.(Form designed for use on elite(12-pitch)typewnter.) Form Approved.OMB No,2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Pall 1 of 3 E r e cy a nse P 4.Manifest Tracking Number <br /> WASTE MANIFEST CRD98196768@ i °gYa 005521202 SKS <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Stockton Dodge <br /> 3333 Auto Center Cir <br /> STOCKTON CA 95c^12-2837 <br /> Generator's Phone: r7i@@� Q r �6 D <br /> s.-Wa f-�o a�y eSYSTEMS, INC. u.SEPA 1oNumber TXR@00081205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE , CA 95133 <br /> CAD059494310 <br /> 408-441-0962 <br /> Facility's Phone'. <br /> 9a 9b.U.S.DOT Desiccation(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 /> X 1' UN1268, WASTE PETROLEUM DISTILLATES, (� DM e2�j'� P D0@1 D0@8 018 <br /> o N.0.S. , 3, PG II ( 7��'' 213 <br /> Z z. <br /> W <br /> CD <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:SJ 71140167 ST37139 SG: <br /> S � a Lwv <br /> 1)ER6(1128• � <br /> 24 HR E14EASENCY #1-800-468-1760 (SK / TFI) <br /> AUTH AS "AGENT—FOR" <br /> 15. GENERATOR'SIOFFEROR'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 Iabeled/placarded,and are in all respects in proper condition for transport according to applicable international and natlonal 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 282.27(a)(if I am a large quantity gerigipill or(4M I am a small quantity g or)is truA 0q <br /> - sl rocs PflntedrTyN, Name Si atu a Mcum D Y,qp <br /> j 16 Intem oval Shipments <br /> r Importto U.S. Export from Partof entry/e '. <br /> Transporter signature(for exports only). Date leaving .S.' <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> OT s at i PnnledlTy_;me Signature Mont DayY,ar <br /> CIL <br /> Z Transport 2 Pn ed/fyped Name Signature Month Day Year <br /> 6 <br /> K <br /> r <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Fal Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> E5 <br /> 1 Facility's Phone: <br /> w 18c Signature ofAhemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> H19.Hazardous Waste Report Managem nt M thod Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1. 2. <br /> 20.Designated Facility Owner or Operator:Certificafion of receipt of hazardous marshals covered by the manifest ex ce as ncled in girn 1 <br /> 1 Pri edrryped ame Signatur Monh Day Year <br /> L <br /> EPA Form 8700-22(Rev.3-05 Previous lions areob te. ESIGNATED CILITY ODES INATIONSTATE(IFREQUIRED) <br /> 1)7841976/124 752 <br />