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SSL HIt#1 11%870 <br /> Please print or type.(Form designed for use on elite(12•pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number CALOW346561 2.Page Of 3.1T1 Rgs@�ase Plfgttg_ 4.Manifest�ac�Nu 8 09 SKS <br /> WASTE MANIFEST k3ft>lb-4t)tS"I7biP <br /> -- S.Generator-$Nameand Mailing Address Generator's Site Address(if different than mailing address). <br /> TCi <br /> 2150 W Charter Way <br /> STOCKTON CA 95206-1118 <br /> Ganeretor's Phone: 209-941-4034 <br /> 6.Tei 91"?—nnKtM SYSTEMS, INC. U.S.EPA ID Number T X RNSW I205 <br /> 7.Transporter 2 Company Name N U.S.EP6 IDN be 1 <br /> f 11 A <br /> 8.Destgnated Facility Name and Site Address CLEAN HARBdRS OF WILMINGTON LLC U.S.EPA ID Number <br /> 1737 EAST DENNI STREET <br /> WILMINGTON CA 90744 <br /> 310-835-9995 CAD04442%35 <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 /> HM and Packing Group(V any)) No. Type Quantity Wt.No4. 13.Waste Codes <br /> 1 <br /> (OIL AllARDOUS WASTE, SOLID DM i P 2223 <br /> z 2. <br /> v <br /> I <br /> 3. <br /> i <br /> 4, <br /> i <br /> i <br /> 14.Spacial Handling Instructions and Additional Information TSD:WI 72355688 TC19591 - CSG: - <br /> ,AMR EMERGENCY 81-500-468-1760 (SK f TF1) <br /> AS ENT-F Y G <br /> 15. GENERATOR'S10FFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fullypnd accurately described above by the proper shipping name,and are classified,packaged, a <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the cements of this consignment conform to the terms of the attached EPAAcknowledgment of Consent <br /> I certify that the waste minimization statement identified in 40 CFR 26227(a)if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generaor's/Otferoes Printed/Typed Name v. Signature Month Day Year <br /> 16.International Shipments 117 <br /> f— ❑Import to U.S. Export from U.S. Pat of entrylexit: <br /> 2 Transporter signature(for exports only): Date leaving U.S.: <br /> W17.TransporterAcMawledgment of Receipt of Materials <br /> Tr po r 1 Printedlry Namevv <br /> n A Signature Month Day Year i <br /> O Q V Y' 16 1/7 <br /> CL <br /> Z Transporter ZPrinVotcl Name Signature Monde Day Year 'f <br /> 16.Discrepancy I�tr- <br /> 18a.Discrepancy Indication Space ❑Quantity L._rly ❑Residue <br /> ❑Partial Rejection ❑Full Rejecdon <br /> Manifest Reference Number. - <br /> IZ 18b.Alternate Facility(or Generator) U.S.EPA ID Number - <br /> J <br /> Ll <br /> LL Facilky's Phone: <br /> W 1lic.Signature of Alternate Facility(or Generator) +. Month Day Year <br /> Q <br /> Z � i <br /> 19.Hazardous Waste Report Management Method Codes(ke.,codes for hazardous 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 except as noted in Item 18a <br /> Print d Name Signalkq &v Month Day Year <br /> EPl F%VgW fjj 3 451_Pfvious editions are obsolete. <br /> DE ATED FACILITY TO GENERATOR <br /> _. .._..))_:.. 112280.33—/._1.5_67777 <br />