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SSL SK SHIP# 226543487 (IIIIII II "II �I � 'IIIII�IIIIIIII IIIIII <br /> 0067777155 K $ <br /> Please print or type . Form Approved . ONE No . 2050-0039 <br /> 1 . Generator ID Number 2 Pae of 3 . e R P 4. Manifest TrackingNumber <br /> UNIFORM HAZARDOUS CAL0003278 ' 9 ! v I ��� -- 5 �v' 006777715 SKS <br /> WASTE MANIFEST v <br /> 5 . Generators Name and Mailin Address Generator's Site Address if different than mailing address) <br /> Les Schwab Tire Center 673 <br /> 1717 W Charter Way <br /> STOCKTON CA 9520£- 1114 <br /> Generators Phone : 805 - 438 - 5487 <br /> 6 . Tit t — SYSTEMS INC U . S . EPA IONumher TvR000081205 <br /> 7 . Transporter 2 CompanyName U . S. EPA ID Number <br /> CLERN HARBORS ENVIRONMENTAL SVC INC . MAD039 . - . ' l <br /> e . Designated Facility Name and Site Address CLEAN HARBORS GRASSY MOUNTAIN U . S . EPA ID Number <br /> 3 MILES EAST , 7 MILES NORTH KNOLLS EXIT 41 , OFF I -80 <br /> KNOLLS , UT 84083 <br /> 435 - 884 -8915 UTD991301748 <br /> Facilitys Phone ' <br /> 9a 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 Wtivol . <br /> 1 . NON RCRA HAZARDOUS WASTE SOLIDS ( DIRT ( DM �� P 352 <br /> 0 , SAND , SOIL , ABSORBENT AND OIL <br /> w <br /> Z 2 . <br /> w <br /> r, <br /> 3 <br /> 4 . <br /> 14 , Special HandtingInstructors and Additional Informal TSD : SM 77849655 LEI3l CSG : <br /> 24H EMERGENCY # 800 -468 - 1760 — CH / SK / TFI — Contrast retained by generator confers agency authori v <br /> on initial transporter to add or substitute additional transdhrters on neneratorls behalf . <br /> 15 . GENERATOR ' S/OFFEROR 'S CERTIFICATION : I hereby declare that the contents of this consignment are fully and accurately descd abo by Na proper shipping name, and are classified , packaged <br /> marked and labeledlplacarded , and are in all respects in proper condition for transport according to applicable lime ational and nation govern ental reP=ns . 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 EPAAcknowledgm of C sent . <br /> I certify that the waste minimization statement identified in 40 CFR 262 , 27(a) (if I am a large quantity generator) (b) 1 am a uan6 nerator) is We . <br /> Generalor'slOfferors Friom yea <br /> Name Signal Month Day Ye <br /> � M � uc -Y1Ml <br /> 16 . International Shipments ❑ Import to U . S . ❑ Export from U .S . V Pon of entryle <br /> r <br /> = Transporter signature (for exports only) : Date leaving U .S . : <br /> W 17 . Transporter Acknowledgment of Receipt of Materials <br /> Transr 1 PnntedlT Name Sign atu i+ Month Day Year <br /> aTransport 2 P tediTyped Name Signature Month Day Year <br /> Mel 1 04�6" L Ile <br /> t18 . Discrepancy <br /> 18a . Discrepancy Indication Space ❑ Quainty ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection <br /> Manifest Reference Number: <br /> 1 B6 . Akemate Facility (or Generator) U . S . EPA ID Number <br /> U <br /> LL Facility's Phone. <br /> W 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> a <br /> Z <br /> h19 . Hazardous Waste Report Management Method Codes (i .e. , codes for hazardous waste treatment , disposal , and recycling systems) <br /> � 1 . 2 . 3 . <br /> 1 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest etas as need in Item 18a <br /> Pr' e Sig re nth Day Year <br /> \ Mol0eL 1 <br /> EPA )o� d6 v1N .41? q, ous editions are obsolete . DESIGNWED AC � L � � '( TO EPA's e - MANIFEST SYSTEM <br />