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GSL SK SHIP# 9-2��ML' o o e T 9 3 4 7 3 s +c s <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> 1.Generator ID Number 2.Page 1 of 3.Erne envy Response Phone 4.Manifest Tracking Number <br /> UNIFORM ANtFES HAZARDOUS1006193478 SKS <br /> WASTE �s��17�i� <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> lift Trats ortat ion Cc <br /> ft Darcy pkwy <br /> LATHROP CA 95330-8764 <br /> venerator; hon:. 77027 <br /> anNa1T38. U.S.EPA ID Number <br /> SYSTEMS INC TXROON812 <br /> 7 Trartsporter2CompanyName U.S.EPA ID Number <br /> ENTAL SVC INC. A 322250 <br /> tk t3 led Fadi f} ame�r d-Site AddFess CLEAN HARBORS ILMI TON LLCU.S.EPA ID Number <br /> 17,37 EAST DENNI STREET <br /> WILMINGTON , CA 90744 <br /> � � CAU044429835 <br /> d a{3CfTi3estdrptwn,(peloding Proper Shipping Name,Hazard Glass,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> ' atsrQup( r€f)) No. Type Quantity Wt.Nol. <br /> g tFe II3 IP 223 <br /> � 4 <br /> F <br /> '9g ' '` <br /> I <br /> 4. <br /> --174.Secial Handling Instructions and Additional informationTSD:WI 75159W3 SW10083 CSG. <br /> r <br /> 24 HR EMERGENCY #1-802--468-176 (SK I TFD <br /> 15. GENERATOR'SlOFFEROR'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 /> I marked and Iabeledlplacarded,and are in all respects in pmper condition for transport according to apphcable'international and national governmental regu#ations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a Iarge quantity generator)or(b)(i m a small quantity generator)is true. <br /> K <br /> Generaloi`$101�9(prs Printedityped N e Signature Month Day Year <br /> Uvv/ � <br /> 116.Intemafional Shipments <br /> r- ❑Import to U.S. ❑Export from U.S. ort of entrylexit: { <br /> Transporter signature(far exports orgy): Date leaving U.S.: v z <br /> 17.Transporter Acknowledgment of Receipt of Materials ! z <br /> P" <br /> :TransPoiter 1 Printed/Typed Name Signature Month Da <br /> D <br /> q_5 4 <br /> ..`';Trarisporter2Pdnte ed Name Signature Month <br /> 18.Discrepancy <br /> 18a.Discrepancy Indicaflon SpaceFuW <br /> ❑ Quantity ❑Type ❑Residue ❑Partial Rejection <br /> Manifest Reference Number: <br /> �7 18b.ARemate Facility( )or Generator U,S.EPA IO Number <br /> �i <br /> LA- Fadi Phone: a ' <br /> 18c.Signature of Alternate Facility(or Generator) ,' <br /> v= 19.Hazrdous Waste Report Management Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) � ± <br /> u <br /> et 1. 2. 3. 4. �> . <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as nded in Item 160 +r, <br /> FrintedtTyped Name <br /> Signaturez <br /> i'-FA Form 8700-22(Rev.3-05) Previous editions are obsolete. D SI N Cj C€LETY To 0� T <br /> 1 a 761 eC3/I56777 <br />