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SK SHIP# 229334275 Please print or type. _ Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 99 of I. mere Rqs e Pho e.. 4.Manifest Trackin Numbb �(c WASTE MANIFEST CAR000S530� 1 kg1 4ts 1 r9taki 10071 8962 S I�t7 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) I +:N t1,2t ,A 3450 Auto Plaza Pkwy TRArY CA 953716-01600 Generator's Phone: 805--830--3642 6.Transporter 1 Company.Name, SYSTEMS INC U.S.EPA ID Number T X R00008l 205 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address CLEAN HARBORS Et_ DORAPA], 1,I•C U.S.EPA ID Number 309 AMERICAN CIRCLE: EL DORADO AR 71730ARD0697481 92 870--863--717370--863--7173 ' Facility's Phone: ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes 1. RQ UNt950, WASTE AER06111-8, t:FACH NOT D001 DOOn D006 o EREEDING i L CAPACITY'), P00i D008 331 W Z 2. LU 3. 4. 14.Special Handling Instructions and Additional Information TSD:El80'376760 TR34107 CSG ?. EREa##Ia6* :'4H EMERG�NC:Yd#( ._468-1'7160—CP4/SK/TrT--C;Dntract retained try leder ator cenfers a Percy Ruthor:i .v �ti� lnw•}'i:-,1 {M.,=1r, tn.,b qY^ �;1� :�r��'t Bei" ss ti!-.,j�". � i• :•t "F - 15. GENERATOR'S/OFFEROR'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 labeled/placarded,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 EPA Acknowledgment 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 true. Generators/Offeror's Printed/Typed Name Signature Month Day Year J 16.International Shipments Z ❑Import to U.S. ❑Export from U.S. Port of entry/exit: Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials LLI F Transporter 1 Printed/Typed Name Signature 0 Month Day Year a Z Transporter 2 Printed/Typed Name Signature Month Day Year 18.Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑TypeResidue ❑ ❑ Partial Rejection ❑Full Rejection Manifest Reference Number: 18b.Alternate Facility(or Generator) U.S.EPA ID Number J V LL Facility's Phone: UJ Q 18c.Signature of Alternate Facility(or Generator) Month Day Year Z N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) D 1 2• 3. 4. 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a PrintedfTyped Name Signature Month Day Year EPA Fo 11 8700-22 Rev.12-17) Previous editions are obsolete. GENERATOR'S INITIAL COPY