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SGL SK SH <br /> 006i000336K8 <br /> PWM print or type.(Form d i edforusson"(120M)MwKilt0t) Form Lp�ved-OMB No.20%M39 <br /> Generator ID Number 4.tilam TnAft Nvanbar <br /> UNIFORM 1.FORM HAZARDOU CAL000122264 6100033 SKS <br /> WAM MANIFEST Ske �mw(ffdff1lefW IMIN address) <br /> T—Gwemwes Name and MdWQ Ad&m <br /> Tracy City Airort <br /> 5749 S Tracy Blvd <br /> TRACY CA 95377-8116 <br /> Ge"rator's Phone: U.S.EPA ID Number TXROOOOB1205 <br /> 999-999-9999 <br /> 'TffnYf-"ff9?-R SYSTEMS INC <br /> 7.Transporter 2 Company Nam U.S.EPA ID Number MAD03932R250 <br /> CLEAN HARBORS ENVIRONMENTAL SERVICES INC <br /> 8.DaValed Facility Nam and Site Addrm CLEAN HARBORS ENVIRONMENTAL SERVICES, IN U.S.EPA ID Number <br /> 2247 S HIGHWAY 71 <br /> ciltW308-235-4012 KIMBALL NE 691.45 NED981723513 <br /> Fae Phone: <br /> H. <br /> 9b.U.S.DOT Description Cirduft Proper Shipping Narm Hazard Cess,ID Number, 10.Containers 11.Total 12.Unit 13,Waste Codes <br /> HM sndPad&vGW(if any)) No. Type Quantity Wuvol. <br /> —X T­4143121182, HAZARDOUS WASTE LIQUID, DM P DOIBIR23 <br /> N.O.S., (BENZENE), 9, N.3- III *2 0 <br /> 2. <br /> 3. <br /> 4. <br /> 14.special Harding instructions and Additional inlormation TSD:KP TR34054 CSG: <br /> I)ERG#171' <br /> 24 HR EMEAGENCY #1-800-468-1760 (SKI TFI) <br /> AUTH AS "AGENT--FOR" BY GEN TO REJAIN Lj!;ENSER SUB CAROI9 S AS NECES <br /> 15 MNMAMW&MIFFEROWSCERTMATB:I hereby declare that to mftft ofthis coraWment as fift and accurately described above by the proper sh1pp1ni;rem,mid am classulled.pacluilied, <br /> marked and labeled"carded,and are In all respects in proper condition for tramsport according to applicable Intsmational ad national gmmffwdW reF101tions.N export shorumt and I am the Primary <br /> ExporW I ce*that the contents of this consiljnmant ounbm to the terms of to affached EPAAdmowledgnent of Consent <br /> i car*that the waste rninhustion statement Identified In 40 CFR 262.27(a)Cd I am a larp quantity g_wW9Q4.Z0j(if i am a am#quantity pnerator)is true. <br /> GimeraftWOffames PikiW— yped Name -,%rusura fA Month Day Year <br /> k"A4t!�v M Jos I zy I <br /> —1 16,internationsi Shipments <br /> El import to U.S. FlEwn from U.S. Pod of6wadt <br /> Transporter signature(for exports only): Data 188VN U.S.: <br /> 17.TransialerACIMMedpW of Rw*of Materials <br /> Transporter I Printed/Typed Nam Signature Month Day Year <br /> JOS I 2,S-1 1-7 <br /> Tre <br /> STIVJE MUL�-Vk--J <br /> 1 2 Ptintedayped eme Month DW yew <br /> r -n— <br /> Dim 1/7 <br /> 18.Discrel nCy <br /> 18a.Discrepancy Indication Space F1 Quantity ❑Type El ftaidue ❑Partial R*dfon ❑Full Nisclion <br /> Manhg Reference Number. <br /> Ift.AJWmab Facility(or Generator) U.S.EPA ID Number <br /> Fadiltys Phom: <br /> 18c.ftnature of Alternate Facility(or Canerab) Month Day, Yew <br /> 19.Hazardous Waste Report Managwrient Method Codes(i.e.,codes for hazardous waste irgatnent,disposal,and recycling systems) <br /> UK 1 2. -13. 4. <br /> 20. Facility Facility Owner or of rocNpt of matedfals covered by the mantfastexc as noted hbfnlga <br /> — - F <br /> PrintetTyPid Nam signature <br /> I <br /> EP -4� V? <br /> t�Qgyg�j Xyj 4&6 T GNAT TO STATE(IF REQUIRED) <br /> ,�us edifions am obsolete. <br />