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SK SHIP#t 225510545 IlINI1I�IIRi�N11l��f��l��l� <br /> 006462 4295 KS <br /> Please print or type,(Form designed for use on elite(12-pitch)typewriter.) Farm Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1'Generaldr l0 Number 2.Page 1 ai 8.Emergency Response Phone 4,Manifest Track! umbar <br /> WASTE MANIFEST CAL_0L►0433184 1 1-800-468--1760 006462429 SKS <br /> 5.Genaralor's!Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Ptin,sPe Truck Leasing <br /> 9409 Arbor Ave <br /> TRf7CY CA 35:304--0000 <br /> Generalo?s Phone: <br /> 8.Transporter 1 Company Name U.S.EPA ID Number <br /> SAFETY--KI-CFN SYSTEMcy INC TXROQ0081205 <br /> 7.Transporter 2 Company Name U.S.EPA!D Number <br /> CLFAN HARBORS ENVIRONMENTAL_ SVC INC. MAD1113932 ti 30 <br /> S.Designaled Facilily Name and Site Address U.S.EPA ID Number <br /> CLEAN HARBORSF�iV JUST <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE , CA 95133 <br /> Fadi' s Phone: <br /> 408--441-0962 CAD059494310 <br /> ga. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) 13.Waste Codes <br /> No. TWO QuanBty WtNol. <br /> t NON RC:RA HAZARDOUS WASTE SOLIDS L UM "Tor-) P w2:3 <br /> (DERRTSy PETROLEUM HYDROCARBONSI <br /> z 2. <br /> w <br /> (7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instractions and Additional Infomiallw, <br /> TSI}:SJ 76917471 PE35618 CSG <br /> 24 HR EMERGENCY #1--800-468-1760 (CH / SK / TFI) au I O <br /> 15. S I declero Il the n oorrsrgnn,an!are a acture "bed <br /> marked and labeled! carded,and are In all res y ,P� ng name,and are classlred,padcagod, <br /> f p"in proper condibon for transport according to applicable hlematforteland national gamnmental regulations.If export shipment and 1 am the Primary <br /> Exporter,i ce*that the contents of ft ww1gmT*M conform to the terms of the attached EPAAclu valedgmant of 964t. <br /> I certify that the waste min lion stalarnent Identified in 40 CFR 26227(a)('d I am a large quantitygenarsttor)or bAfff a4 a mall quantity gerleraier)Is true. <br /> Generalcr s Prin me re Month ua Year <br /> IT <br /> ...r 16.international Shipments <br /> Transporter signature(for exports an❑Impwt to U.S. ❑Export from U Port of Date leaving U S: <br /> H)' n9 <br /> 17.TmnsporSarAcArwwledgn*nt of Receipt of Materials <br /> Transporter 1 PrinlacfTyped Name SignatureMonth Day Year <br /> —AZ 1.0_5 <br /> Transporter tfyped Name �p Signalure Month Day Year <br /> av, <br /> 18.Dlscrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Re)ectlon ❑Full Rejection <br /> Manliest Referenoa Number. <br /> 18b,Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL FadWs Phone: <br /> C3 <br /> 18c.Signalure of Alternate Facility(or Generator) Month Day Year <br /> 4F- <br /> 19. <br /> 19.Hazardous Waste Repan Management Method Codes(i.e.,codes for hazardous waste tmatrrwnl,disposal,and recycling syslems) <br /> wo 1. f/ �, 2. <br /> 20.DesigTA Facilityr0,5wf or Operaiar.CarllhuekD ipl of hazardous materialsyw0god by the manifest exSv4es3W In Item 1 <br /> Pan Signa M aY <br /> EPA Y22v.(4Rey ' Pirevilchfg eibdns are obsolete. DESIGNATED FACILITY TO DESTINATION STATE(if REQUIRED) <br /> 1 )632249:31.!I F-,15176 <br />