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SSL SK SHIP# 226941980 11111111 111111IN11111111 M11111111 <br /> 0066872993 Ks <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number CAL000433184 2.Pagei of 3.jmem§Ly RBspT PMS L N60668 <br /> ni s;Trac lnQ Numhar <br /> WASTE MANIFEST tS 1t3 x+413 SKS <br /> 5.Genemiors Nama and Wl:ng Address Generator's Site Address(rdiRerenl than mailing address) V <br /> Penske Truck Leasing <br /> 9409 Arbor Ave <br /> TRACY CA 95304-0000 <br /> Gemralods Phone: 209-831-0026 <br /> 6.TWgiM— M SYSTEMS INC U.S.EPA ID Number TX R000081205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENVIRONMENTAL SVC INC. MAD039322250 <br /> S.Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE U.S.EPA tD Number <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE , CA 95133 CAD@59494310 <br /> 408-441-0962 <br /> Facility's 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. I Type OuanBty Wl Nal. <br /> 1. NON RCRA HAZARDOUS WASTE SOLIDS r DM Z� P 223 <br /> o (DEBRIS, PETROLEUM HYDROCARBONSI <br /> Z 2 <br /> 3. <br /> 4. <br /> 1 .5peclaI H70diing insinx;tions and Additional niormatioriTSD.-SJ 78339709 PE35618 CSG <br /> 24H EMERGENCY#800-468-1760--CH/SK/TFI—Contract retained by generator confersa ency authori y <br /> on initial transporter to add or substitute additional- transporters on enera or' ehalf <br /> 15. GENERATOR'5FDFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are luny and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,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 <br /> Exporter,I certify that the contents or this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I Wiry that the waste minimization statement identified in 40 CFR 262.27(a)(if i am a large quantity generator)or(b)(III am a small quantity generator)is true. <br /> enwators106eroes PrintedfTyped N me Sig lure Month Day Year <br /> G <br /> 16.Inlemational ipmerts ❑ExertiromU. . Porlofentrylexit: <br /> ❑Import to U.S. p Date leaving U.S.: <br /> ? Transporter signature(lor exports only): <br /> I= <br /> 17.Transporter Acknowledgment of Racelpl_ol Materials <br /> Transporter I PrinlegrypedNamaS, ME" �.! 1 9r�wre I I Year <br /> p yFf Ti[I�. r � /�� <br /> ZTransporter 2 Printedflgped Name atur MogEI <br /> �+�.l+- if <br /> 1 B.Discrepancy <br /> 18a.Discrepancy Indication Space Quantity E]TypeEl Residue <br /> ❑Partial Rejection ❑Full Re)ectlon <br /> Manifest Rererence Nurmber: <br /> J S.EPA IDNuiwhw <br /> 18b.Alternate Facility(or Genoralor) <br /> 7 <br /> L) <br /> ua Fac lily s Phone: Month Day Year <br /> W 18c,Signature of ntemato Faculty(or nwator) <br /> Q <br /> Z s lams) <br /> 19.Hazardous Was Repoli Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling ys 4 <br /> w 1 ILI <br /> 2. I <br /> . <br /> D <br /> 20.Designated Faclrly r Operator:Ce 'rrca4on r or hazardous materials covered by the anifest except as in Ite Ba <br /> Prints yped Name � Signature <br /> TA <br /> 11 DESIGNATED FACILITY TO EPA's a4mwILr;:�'.;_ySTEM <br /> EPI�����(R�rv1621�� 91 s <br />