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SS1_ SK SHIP# ?e ''T,�;9 � III0�IIIII2IIIII�II�3�IIIII2 <br /> Please print or type.(Form designed for use on elite(12-pitdl)typewriter.) M1"/ Form Approved.OMB No.X200500- <br /> --0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phoma 4.Manifest Tracking SKS <br /> Number 3 S <br /> WASTE MANIFEST CAD981967680 1 1-800-468- .76000572890 <br /> 5.Generators Name and Mailing Address Generators Site Address(8 different than mailing address) <br /> S16ackton Dodge <br /> 3333 Auto Center Cir <br /> STOCKTON CA 95212-2837 <br /> Generator's Phone: 441-000-3000 <br /> 6.Transporter 1 Company Name U.S.EPA ID Number <br /> SAFETY-KLEEN SYSTEMS, INC. <br /> TXR4'7QUA122` <br /> 7.Transporter 2 Company Narne U.S.EPA ID Number <br /> ( v�j 6 AI u baa <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 /> 408-441-0962 CRD0S9494u10 <br /> Fadlitys Phone: <br /> 9a 9b.U.S.DOT Description(including Proper Shipping Name,Harsh Class,ID Number, 10.Containers 11.Total 12.Ung 13.Waste Codes <br /> HM and Packing Group(it any)) No. Type Quantity WLNd. <br /> X 1. UN1268, WASTE PETROLEUM DISTILLATES, t DM P D001 DOOR DO16 <br /> or N.0.S. , 3, PG 11 f <br /> 213 <br /> i 2. <br /> W <br /> 3. <br /> 4. <br /> 14.Special Handling Insinuations and Additional Information TSD:SJ 5'13713 CSG: <br /> 1)ERG#128• S - 1 (06 Z� II I <br /> 24 HR EMERGENCY #1-800-468-1760 (SK ! TFI) `f <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 Iabeledlplac noted,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 tens of the attached EPA AduroMedgment of Consent. <br /> I candy that the waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quantity generator)or(b)(ifI am a small quantity generator)is We. <br /> Generetors/Offerors Pnntedrryped Name ^ Signature Monts Day yeaA <br /> re �Lh 3 11/c"J <br /> 16.International hipments <br /> t- ❑Impart to U.S. Export from U.S. Port of entrylezit: <br /> = Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.Transporter Acknowledgment of Receipt of Materials <br /> Trar7er1 Pdntedrryped Name signaturl Month Day Year <br /> a <br /> 1 // 3 16 <br /> Transport2 Pd Name Signature Month Day, Year <br /> r {1 <br /> 18.Discrepancy <br /> real.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue j ❑Full Rejection <br /> ❑Partial Reaction <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Fadlitys Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> G <br /> 2 <br /> H19.Hazardous Waste Report Management McMod Codes(is.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> i. 2. 3. 4. <br /> 20.Designatedcility Owner or ratoc Cenficabon of receipt of hazardous matenals covered by the manifest ezce s noted in Ite 18 <br /> 11I PrinledRyped me Signatu Month Day Ye r <br /> V 14 <br /> EPA Form 8700-22Rev.3-0S Previous editi areobsole D GNATEDFAC UIR <br /> YTO STINATIONSTATE(IFR ED) <br /> 1)7841976/124752 <br />