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SSL SK SHIP # 2 .30423160 I� IIIIIIIIIIIIIIIIIIIIIIII�IIIIII 'II <br /> Please print or type . O O Form Approvved OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number CAL000327839 2 . Pagell of 3 . Em�gnyy Resyppse I"'M0 4. Manifest Tracking Number �( �+ <br /> WASTE MANIFEST 1 tllfRrl 4ttH / E 1007275089 SKS <br /> 5 . Generator's Name and Mailing Address Generator' s Site Address (N different than mailing address ) <br /> L_ es Schwab Tire Center 673 <br /> 1717 W Charter Way <br /> STDICK TON CA 95206 - 1114 <br /> Generators Phone : 805 - 438 - 5487 <br /> 8 . Tran nes 1 Compan Name U . S. EPA ID Number <br /> S (� ETY - K. L� EN SYSTEMS INC TXR001ia! 5. ; ' <br /> 7 . Transporter 2 Company Name U .S . EPA ID Number <br /> CLEAN HARBORS ENV SVC INC . MAD0393222 .' 1' <br /> 8. Desigi Facility Name and Site Address CLEAN HARBORS SAN JOSE U.S . EPA ID Number <br /> -sv, 1021 BERRYESSA ROAD <br /> SAN JOSE , CA 95133 <br /> 408 - 441 - 0% 2 CRi� 05 ? 494310 <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 <br /> and Packing f an 73 . Waste Codes <br /> n9 Grou <br /> HM PG Y)) No . Type Quantity Wt.Md . <br /> X 1 NA3077 HAZARDOUS WASTE , SOLID , N . O . S . I 1"r d P D007 181 <br /> or ( CHRbMIUM ) , 9 , PG III <br /> qa <br /> w <br /> Z 2 <br /> w <br /> 3 . <br /> 4 , <br /> 14 . Speaal Handling Instructions and Additional information To : S J 81983951 LE 1. 52: . CS <br /> 1 ) ER8 # t7t • <br /> ? 4H EMERGNCY # 800 - 468 - 1760-- CH / SK / TFI - Contract retained by generatesconfers a ency a _tthnri <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION : I 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 labeledlplacamed , and are In all respects in proper condition for transpo according to appliceWe international and national governmental regulations , 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 Consent . <br /> I panty that the waste minimization statement identified in 40 CFR 262 ,27(a) (if I am a large quarmy generator) or (to jif I am a son qu n rat is We . <br /> Generator roes P ' ntedlTypetl Name Signature Month Day Year <br /> c see X l5 <br /> 16. International Shipments <br /> F ❑ Import to U . S . ❑ Export from U .S . Pod of entrylexA: <br /> ? Transporter signature (for exports only): Date leaving U .S. : <br /> W 17 . TransporterAcknowledgreint of Receipt of Materials <br /> Than er1 Pritedn Name Signature Month Day Y" <br /> nYear <br /> a cc — _ 7 Ot <br /> Z <br /> Treft 2 Pri tedrryped Name Signature 7 Month Day Year <br /> r18. Discrepancy <br /> 18a . Discrepancy Ind'anon Space ❑ Quantity ❑ Type ❑ Residue ❑ Partial Rejeclim ❑ Full Rejection <br /> Manifest Reference Number: <br /> 18b . Alternate Facility (or Generator) U .S . EPA ID Number <br /> J <br /> Q <br /> LL Fadliys Phone : <br /> QW 18c. Signature of Alternate Facility for Generator) Month Day year <br /> 2 <br /> y19. Hazardous Waste Rejor Manaqajisent Method Codes (ia. , codes for hazardous waste treamient disposal , and recycling systems) <br /> UJI <br /> 1 . 2 . 3, 4 <br /> 20 . Designated Facifftybfier"llilirator Ce cation of azardous materials covered by the mandest except as nor 18a <br /> illl PrintedRyped Name Signature M th <br /> 12 <br /> EPA Form 87M 2 (Re . revious edi ions solete . DESIGNATED FACILITY TO EPA's e•M IFEST YSTEM <br /> 1 ) 7706779 / 11L: 149 `1ar <br />