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SSL SK SHIP# 226543502 11!1111111111111111111111 <br /> 4057777 '153 K3 <br /> Please print or type. Form Approved.OMS No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number CAL000;.2783'3 2.Pae 1 of 3.lm g 2mri- fto 4.ManitTrackin Number <br /> WASTE MANIFEST 10567 7 716 SKS <br /> y 5 Ggnerators Name and Maili Address Generator's Site Address Vdifferent than mailing address) <br /> L.es SCItwab ire Center 673 <br /> 1717 W Charter Way <br /> STOCKTON CA 95205-1114 <br /> Generator's Phone_ 805-438-5487 <br /> 6,TrgWfErt jpr &R SYSTEMS INC U.S.EPA ID Number TX R1300081205 <br /> 7,Transporter 2 Com an Name U.S.EPA ID Number <br /> CLEAN HNNORS ENVIRONMENTAL_ SVC INC. MAD039322250 <br /> 8-Designated Facility Name and Site Address CLEAN HARBORS ENV I RONMI`NTAL SERVICES, IN U.S.EPAID Number <br /> 2247 S HIGHWAY 71 <br /> KIMBALL NF 59145 <br /> 308-235-4012 NED98 172.32513 <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group{if any)) No. Type Quantity w1.Nol. <br /> 1. NONE NON RCRA HAZARDOUS WASTE LIQUIDS � DMP P 343 <br /> c (GLYCOL_ ETHER, WATER), *R W�1 <br /> LU <br /> cs <br /> 3. <br /> 4. <br /> 14,Special Handling Instructions and Additional Information TSD'KP 77849655 LE 15361a�'G' <br /> 1 yo L41 <br /> 24H EMERGENCY#[800-468-1750-CH/SK/TFI-Contra^t retained by generator confers agg ney at_tthori y <br /> on initial transporter to add or substitute additional trans ort Ws an enerator' s behalf. <br /> 15, GENERATOR'SIDFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately desaibad above a roper shipping name,and are dassifred,packaged, <br /> marked and labeled/placarded.and are in all respects in proper condition for transport according to applicable international and national grrvem ntal ulations.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 CIillrisent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or Wil a9p small u ' gen tar true. <br /> Generatoe, Offe#ed [Typed Name Signature Month Day Year <br /> I Io IIR <br /> 16 Intentallional ShIpRnents <br /> ❑Import to U.S. ❑Export from U.S. ort of en !exit: <br /> ? Transporter signature(for exports only): Date leaving U.S. <br /> W17 Transporter Acknowledgment of Receipt of Materials <br /> II-- 7 oriPrint edlTy ane � � Sigma � �� � <br /> Day <br /> a ear <br /> ZZ Trams Prin hyped NameSignature 1 .. Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quanti <br /> ry El Type Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> w 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 14.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems( <br /> LU 1. 4 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as nded in Item 18a <br /> Printed/Typed Name I t Signature r Month Day P <br /> r I C 10 <br /> EPIC 5oUtJ,5M?yv1 l Agious editions are obsolete. DESIGNATED FACILITY/O A'S e-MANIFEST SYSTEM <br />