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SE�t_ SK Sf l I P# 2285 r 4946 r i Please print or type. Farm Approved.OMB No.2050.0039 UNIFORM HAZARDOUS 1.Generator 1D Number 2•Page 1 of 3. me R s se Pty, 4.Manifest Tracking Number WASTE MANIFEST CAIw.00Ib0156,�8 � �� j�� 100696 145 SKS 5.Generator's Name and Mailing Address Generators Site Address(if different than mailing address) San Joaquin Co Maintpnanr:e 1810 E Hazelton Ave STOCKTON CA 95209-6 3a Generators Phone: 209-468-3099 6.Trfngr`r i Y°Tp � SYSTEMS INC U.S.EPA ID Number TX ROO0001205 7.Transporter 2 Company Name U.S.EPA ID Number CLEAN HARBORS ENVIRONMENTAL SYC INC. MAD:039322230 B.Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE U.S.EPA ID Number 1021 DERRYESSA ROAD SAN JOSE , CA 55133 408-'441-0962. CAD059494310 Facility's Phone: !! ga• 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,10 Number, 10.Contalners 11,Total 12.Unit l HM and Packing Group(if any)) No. Type quantity WI.NoI. 13.Waste Codes NON RCRA HAZnFiLTGUS WASTE SC1UDS DSI P 22 t o 4DEBRIS, PETROLEUM HYDROCAR6DN@ W c� k: 3. k 4. i; 14.Special Handling Instructions and Additional Information TSP=.9J 8017020.7 9[43P680 C881 R4H EMERGENCY# 800-,468-176th--CHiSKITEI-'Contratrt retained by IMeneraltor centers a enpy at�lthori y on initial transporter to add or substitute additional t � .� e s r I ' 15. GENERATOR'SIDFFEROR'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, marked and Iabeledfplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgmenl of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is two. GeneratorslOfferors PrintedlTyped Name Signature Month Day Year X _j 16.International Shipments [= 1:1 Import to U.S'. ❑Export from U.S. Part of enlrylexil: ? Transporter signature(for exports only): Dale leaving U.S.: IX w 17.Transporter Acknowledgment of Receipt of Materials Transporter i PrinledlTyped Name Signalure Month Day Year 4 - - Transporter 2 PrintedlTyped Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J U LL Facility's Phone: � 18c.Signature of Alternate Facility(or Generator) Month Day Year Q Z i 55 19.Hazardous Waste Report Management Method Codes(Le,,codes for hazardous waste treatment,disposal,and recycling systems) LU 1. 2. 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as rioted in Item 18a Printed/Typed Name Signature Month Day Year EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY