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' SSI_ SK SHIP# a �J0b;7 1111111111511111111100597 >Sdb $ sKS <br /> Please int or type. (Form designed for use on elite ( 121111 typewriter.) Form Approved. OMB No. 2050-0039 <br /> 1 . Generator ID Number 2. P 1 of 3. R se P 4, Mantfest TracNumber <br /> UNIFORM HAZARDOUS CAL000334985 ; f"—`e ' r— " 1 G 0 0 5 978848 $ KS <br /> WASTE MANIFEST <br /> 5. Generators Name and Mailing Address Generators Site Address (if different than mailing address) <br /> Gordon Trucking Inc <br /> 12550 S Harlan Rd Attn Bob <br /> LATHROP CA 95330-8744 <br /> Generators Plane: 509-640-0555 <br /> 6, T WYI R SYSTEMS INC U.S. EPA ID Number <br /> TXR000081205 <br /> Into <br /> T. Transporter 2 Company Names <br /> U.S. EPA ID Number <br /> 8, Designated Facility Name and Site AddressQ <br /> CLEAN HARBORS OF WILMING N LLC U.S. EPA ID Number <br /> 1737 EAST DENNI STREET <br /> WILMINGTON , CA 90744 <br /> Feat s Plane: 310-835--9998 CAD044429835 <br /> 9a. 9b, U.S. DDT Description Qnduding Proper Shipping Name, Hazard Class, ID Number, 10. Containers <br /> HM and Packing Group (d any)) 11 . Total 12. Unit <br /> 011 <br /> ( LpRDOLS WASTE , SOLID No, Type Quantity WLNd. <br /> 13, Waste Codes <br /> oOILFIT S DMR <br /> � 0 <br /> W 2' <br /> 3. <br /> 4. <br /> 14. Special Handgng lnsh dh)s andAddttionai in nation SCD W I <br /> 73611592 6011213 CSG : <br /> 24 HR EMERGENCY # 1i� 800--468- 176@ ( SK ! TFI ) <br /> 15. GENERATOR'StOFFERrl "OR'S CE1tTiFiCAT10N: I <br /> marked and labeled) hereby declare that the con!; Off this consigrvrx�rrt are fully and acourateiy described above by the proper shipping name, all are <br /> placarded, and are in all respects in proper condition for transport according tu apple" international and national �' <br /> Exporter, I cartiy that the contents of this consignment conform to the terms of the attached EPAftim ledgment of consent tom' If export shipment and am the Primary <br /> ,Exporter, <br /> that the waste minimization statement identified in 40 CFR nw(a) (if i am a large quantity generator) or (D) fam a small quantity di <br /> Generata'slDfierors Printed/typed Name y generaror) is true. <br /> rre Month Day Year <br /> x far �� t� •r �, �c � � �y 1 os t2 �`? <br /> -r; 16. Irdertrational Stripmenis - <br /> z ❑ Import to U.S. ❑ frdm U_S. Port of en ! <br /> — Transporter signature {for exports only): �t Date Ieavl� U S.: <br /> W 17. TransporterAdvawledgment of Receipt of Materials � <br /> Transporter I Prtntedlfyped Name <br /> �I Month Day Year <br /> III rnn y ..l..L. . _ _ oS 12 ! <br /> Signature Month Day Year <br /> 18. isrreparwy - <br /> 18a. Discrepancy irhdicatlon Spacer <br /> ❑ Quantity ❑ Type ❑ Residue <br /> ❑ Partial Re(edbn ❑ Ful Relecilon <br /> 18b, Alternate Facility (or Generate) Manifest Reference Number. <br /> U.S. EPA Io Number <br /> LL Facirdy's Phone: <br /> 18e. Signature o MRemate Fadldy (or Generates <br /> Month Day Year <br /> 19, Hazardous Waste Report Management Method Codes 0,e., codes for hazardous waste treatrnertt disposal, and <br /> recycling systems) IIIII NEW NEW liiiiiiii WON MINE <br /> 20. Designated Facility Owner or Operator: Certification of rooNpt of hazardous materials covered by the manifest except as neled in fte+tt 18a - - - <br /> Pn� dRyped Name - - - - - - - - - - - . <br /> ✓t'� f/p ._ _ - - Month Day._ "Year <br /> _ -- -• - . _. - - � - _ <br /> EPA Form 870622 {{Rev. 3-05 Previous editions are. obsoletg, - -.. .. ..._. . _. _ . �. . __ — — - _:_�. - <br /> 117612003 e - LQ I <br /> I. DESIGNATED EACI�ITYTO DESTINATION STATE (IF REQUIRED) <br />