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I� SK r3flIP# 232486r,31a <br /> Please.print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3. m Res se Rho a 7667769571 <br /> st Trackln Number <br /> AL00034687, 1 m"M81J.90 SKS <br /> WASTE MANIFEST : <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> ADESA W Golden Sate ADESA - Golden Gate <br /> 18501 bust Stanford Rd Attn Samuel Mchenry 1€501 Stanford Rd <br /> TRACY OA 95377 Rtt.n L.est�er Baao <br /> Generators Phone: ~ L 9�3t p TRACY CA 95377--9708 <br /> 6.Tr Spn[ter� orrtp y SYSTEMS INC U.S.EPA ID Number TXR00008121565 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC. INC. MAD039,32225101 <br /> 8.Designated Facility Name and Site Address 'CLEAN H€�RBURS GRASSY MOUNTAIN U.S.EPA ID Number <br /> 3 MILES EAST y 7 MILES NORTH KNOLLS EXIT 419 OFF 1-80 <br /> KNOLLSs UT 84,083435.884-691 S 11TD99 i 3fit 1'748: <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 <br /> 13.Waste Codes <br /> HM <br /> and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> 1. NI1A�. RCRA' HAZARDI J91- WASTE SOLIDS, (LISA T1li 'J;� t� I� 35� <br /> O OIL AND �!l SUPBENTS) � <br /> z 2. <br /> UJ <br /> t9 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSTA A OM 843,94443 AD2@ 198 CSL _ <br /> 24H FMERViF.NCY9#800-468-17668-CH/SK/7FI-Cant ract retained by generator confers ar�en�:y awthori •y <br /> on initial transporter to acid or substitute additional trrans ort�ers on en�r�a ur9 a behalf.. <br /> 15. GEN ERATOR'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 labeled/placarded,and are in all respects in proper condition for transport according to applicable international ancI tional governmental regulations.If export shipment and I am the Primaiy <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent/ t -� <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b),Jif I am''a small quantity generator)is true. } <br /> G ieratoNOfferors Printed/Typed Name Signature Month Day �sYeaf`r <br /> {{L� "' R � <br /> 16.Inter ationalShipments <br /> H ❑Import to U.S. ❑Export from U.S. Port of entry/exit- <br /> LZ Transporter signature(for exports only): Date leaving U.S.: <br /> 17.Transporter Acknowledgment of Receipt of Materials <br /> Transporter 1 Printed/Typed e Suture J Month Day Year <br /> a (� �.t* 4,, tcl� ` "'r 1 <br /> Cn <br /> Transporter 2 Printed/Typed'NameSiglnofure Month Day Year <br /> t- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type <br /> ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> t <br /> U <br /> LL Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. 2. 3. 4. <br /> F <br /> signated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> /Typed Name Signature Month Day Year <br /> EPA Fofn 87.R-22 v. 2-17)„F?� yious editions are obsolete. GENERATOR'S INITIAL COPY <br />