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;SL_ SK SHILL# 2�M14 48 <br /> 0 0 6 7 7 7 7 1 4 S K 5 <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number CAL-000327839 2.Pa e11 of 3.EmelrgV�RVrR11P�efi 0 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUSg t o <br /> 1006777714 <br /> WASTE MANIFE0 0 6 7 7 7 714 SKS <br /> ST <br /> 5.Generator's Name and Mailin Address Generators Site Address(if different than mailing address) <br /> Les Schwab ' ire Center~ F73 <br /> 1717 W Charter Way <br /> STOCKTON CA 9520E-1114 <br /> Generator's Phone 805--418-5487 <br /> 487 <br /> SY;TEMS INC: U.S,EPA fD Number T Y R[2OOOB 1205 <br /> 7.Transporter 2 Com an Name U.S.EPA ID Number <br /> CLEAN HPfl1�AflRS ENVIRONMENTAL. SVC INC:. MAD�i?93'22250 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS 8AN JOSE U-S.EFA ID Number <br /> 11321 PERRYESSA ROPED <br /> SAN JOSE C.A 9512"�; <br /> 4013-441-03E2 ' <br /> CADI<�f5`149431:'i <br /> Facility's Phone: <br /> ga, 91%US.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> X 1. NA3077 HAZARDOUS WASTE SOLID N°d.S. � DM a� P D100-, 191 <br /> o , (CHR6MI11M), 9, RG IIIA <br /> a .] <br /> s <br /> W <br /> z 2. <br /> W <br /> c� <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:SJ 77849655 LE 15361. SEG <br /> 1'1F_.Ra#l71° l�fg Lftwn . r <br /> 24H EMERG�NCY#A01�-4c8-17G0-CH/SK,/TFi-Contract retained by 9etgera © �[eG}(�e* aggenvy authDri y <br /> on initial transporter to add or substitute additional tr,ansportReQ on generAtor°s behalf. <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described abov y the p per shipping name,and are classified,packaged, <br /> marked and Iabelecilplacarded,and are in all respects in proper condition for transport according to applicable internation-and hatlonal gove ental Mations.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 EPAAcknowledgment of C ent. <br /> certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large guantiry generator)or(b) a as mall a gener r)is We. <br /> Genera r's/Offeroes PrintedR ed Name Signature Month Day Year <br /> $�� vrtunn AQ 1 9 <br /> ,j 16.International Shipments <br /> f. ❑Import to U.S. ❑Export from US. Port of en (exit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> LU <br /> Tra iter 1 PrintedRName Si natur <br /> O 9 Month Day Year <br /> EL <br /> 6- 0 I 2 /If <br /> Transpo r 2 P ntedRyped Name Signature / f Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑Quantity ❑Type ❑Residue ❑Partial Rejection Ll Full Rejection <br /> Manifest Reference Number: <br /> F 18b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> W Facility's Phone. <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> d <br /> z <br /> y19.Hazardous Waste Report Management Method Codes(i.e,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU ,. 2. 3. 4. <br /> 20.Designated Facili nar or Operator ertification qf r tof hazardous materials covered by the manifest except as n m i8a <br /> PrintedlTyped Name � Signature <br /> EPAI�opa,87f10: �iou ditions e(e. DESIGNATED FACILITY TG Ei'�:'s e-h7ANlFEST SYSTEM <br />