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0 Ile SSL SK SHIP# 227664202 �IIIIIiII�IIII' IIIII�IIIII�I�I� <br /> 006952610SKS <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.Page 1 of 3.Emer Re p nse Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000327839 i- -4b�8-1760 0069 5 2 610 SKS <br /> 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Les Schwab Tire Center 673 <br /> 1717 W Charter Way <br /> STOCKTON CA 95206-1114 <br /> Generators Phone: 805-438-5487 <br /> 6.Trans oder 1 Com any Name U.S.EPA ID Number <br /> S#�FE+Com EEN SYSTEMS INC TXROZOOB1205 <br /> 7.Transporter 2 Company Name U.S.EPA€D Number <br /> CLEAN HARBORS ENVIRONMENTAL SVC INC. MAD039322250 <br /> 8.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 840$3 <br /> UTD991301748 <br /> 435--$84�-8915 <br /> Facility's Phone: <br /> 9a. go U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> and Packing Group if an Quantity 13.Waste Codes <br /> HM 9 P( YU No. Type h wt.Nol. <br /> 1 NON RCRA HAZARDOUS WASTE SOLIDS (DIRT DM �� P 352 <br /> of , SAND, SOIL, ABSORBENT AND OILS <br /> a <br /> Le <br /> w <br /> Z 2. <br /> w <br /> c9 <br /> 3. <br /> 4. <br /> 14.Speaa€Handling Instructions and Additional Information TSDeGM 79118606 LE15361 CSG: <br /> "ala a , S� <br /> 24H EMERGENCY#800-468-1760-CH/SK/TFI--Contract retained by giner�aREor confers agency authori y <br /> 15. GENERATOR'SJOFFEROR'S CERTIFICATION:1 hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled)placarded,and are in all respects in proper condition for transport according to applicable otemadanal and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment oonform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified In 40 CFR 262.27(a)(If I am a large quantitygenerator)or(b)bill am a small quantity ner V r i ue. <br /> Generate!0 ror's PrinbEcIP56pad N ��—% Signature Month Day Year <br /> � a <br /> 16.Intern onal 5hipments <br /> � ❑import to U.S. ❑Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> IX 17.Trans orterAcknow€edgmentofRepeatofMaterials <br /> Trans 1 PrintedJ7yp me Signature Month Day Year <br /> O <br /> y r P yped Name - S u Month Day Year <br /> 18. iscrepancy <br /> 18a.Discrepancy Indication Space ❑Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manliest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> Facility's Phone, <br /> LU <br /> Month Day Year <br /> 18c.Signature of Alternate Facility(or Generator) <br /> Z <br /> W 19,Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> LU 1 2 3. 4. <br /> l3 <br /> 20.Designated Facility Owner or operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 183 <br /> PrintedlTyped Name Signature Month Day Year <br /> EPA Form 37011 DEPISNATEDFACILITYTOEPA'se-MANIFESTSYSTEM <br /> 1)7857 2/1297433 <br />