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i_ SK SHIP# <br /> Please print or type. (Form designed for use on elite (12 pitch) typewriter.) til 0 5 8 d 3 0 3 2 S K S <br /> UNIFORM HAZARDOUS 1• Generator ID Number 2. Paget of 3. m Fort Approved. OM$ N0. 2050-0039 <br /> WASTE MANIFEST �} L, ao033 c{ q $ s P 4, Manifest Trac ng Number <br /> i. � � 0 <br /> 5. Generators Nam and MaflingAddress 05863 0 3 '2 SKS <br /> ; 'P"* AJ T V6910kli /lj G Generals s Site Address (if different than malting address] <br /> Z S5D ill l�*AL *I All <br /> Generator's Phone: Gl� yh�i�!dl� C/¢ 9d'3 $0 ? 75IN <br /> 8. Trtsppdpr lCnrr pprtu,dcme SYSTEMSi INC., U.S. EPA ID Number <br /> 7. Transporter 2 Company Nam TXR100400081205 <br /> III NIPPON III MINIMUM <br /> U.S. EPA ID Number <br /> 8. sled FaGtity Name and Site Address <br /> CLEAN HARBORS OF WI INGTON LLC U.S. EPA <br /> 1737 1737 EAST DENNI STREET <br /> 310-835-9998 WILMINGTON } CA 90744 <br /> Facility's Phone: CAD0444298 5 � <br /> ga, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, 10 Number, <br /> HM and packing Group (if any)) 10. Containers <br /> 11 , Tofai 12, Unit <br /> 1 . NON—' RCRA HA7.ARDOUS WASTE, SOLID <br /> No. type Quantity WtI 13, Waste Codes <br /> o ( OILFILTERS ) DM P 223 <br /> 2 � .� inn <br /> 3. <br /> 4, <br /> 14, Special Handling Instructions andAdditional information <br /> TSD : WI <br /> CSGft <br /> ALIT24 N AS �PGCNT�FOR " aBYTGEN TO8RETAIN �LICEN � � t <br /> 15. GENERATOWON <br /> R SfOFFEROR'S CERTIFICATION; 1 hereby declare thatthe contents of this ca%ignmi artful)and accuR iy deRscribadaSbovs b tiCie ProparAslrRipp�g name, and are classified, packaged, <br /> marked and certify <br /> that <br /> the contrded, end are In all consignment <br /> respects In proper condition for transport according to appgcable international and national governmental 13Y regulations. If export me, andshipment and ) am the Primary <br /> Exporter, ) certify that tits contents of this consimm�t conform to the terms of the attached EPAAciurowledgment of Consent, <br /> I certify that the waste minimization statement identified in 40 CFR 282.27(a) (ff I ams targe quantity generator} or of o se t, small uanti <br /> 6eneratorslOfferor s PrintedRyped Name 4 . ty generator) is hue, <br /> Signature Month Day Year <br /> International S Ipmnts 0 <br /> F' Import to U.S. <br /> Z Transportersignature (forexportsonl IExport from U.S, Port ofentrylexit: III woul <br /> yj Date leaving U.S,: <br /> w 11. Transporter Adcnowledgmnt of Receipt of Materials <br /> I Transporter 1 PrintediTyped Name <br /> lure / Month Day Year <br /> �' 1 y <br /> Transp 2 priniedityped Name 02 <br /> S gna re <br /> ti Month Day Year <br /> 18. Discrepancy f� . <br /> Ill Discrepancy Indication Space <br /> ❑ Quantify ❑ Type EJ Residue <br /> ❑ partial Rejection ❑ Full Rejection <br /> 18b. Alternate Facility (or Generator] Manifest Reference Number: <br /> V <br /> U.S. EPA ID Number <br /> w Facility's Phone: <br /> 18c. SignatureofAltemate Facility (or Generator) 11 NOMINEE <br /> Month Day Year <br /> UJ 19. Hazardous Waste Report Management Method Godes (1.e., oodes. for hazardous waste treatment, dlsellsand recycling sWIN liiiiiiiystems) <br /> 21 11 Hall TO IIII <br /> 206 Designated Facility Owner or Operator. Certification of receipt of hazardous M8466818 covered by the manifest except as noted in item 18a <br /> P ntedff Name <br /> / fgnature on Day ear <br /> EPA1 7151 7 -1 Form 8700.22 Rev, 3.05 Previous eOlions are obsolete: DESIGNATEQ FACILITY TO bESTiNATION STATE (IF REpUIREQ) <br />