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SSL SK SHIP#/232743995 I�III�IIII�f(I�l��'I�I� I��I <br /> OO77713O6SKS <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number CAL000327339 2.PaiR4qe j0 4.Manifest Tracking Number <br /> WASTE MANIFEST 0 0 7 7 71 8 0 6 SKS <br /> 5. a add <br /> G nerator's e and Mili Aress Generators Site Address(if different than mailing address) <br /> �_es iwaa 1r-e Cent3r 673 <br /> 1717 W Charter Way <br /> STOCKTON CA 95206-1114 <br /> Generators Phone: 805-438-5487 <br /> r�> SYSTEMS INC U.S.EPA ID Number TX RQt@0081205 <br /> 1.TrELpeKNICq,eaxN�yS ENV SVC INC. U.S.EPA ID Number MAD039322250 <br /> tFl t1H1i�11tf � 3--_ <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS GRASSY MOUNTAIN U.S.EPA ID Number <br /> 3 MILES EAST, 7 MILES NORTH KNOLLS EXIT 41, OFF I-80 <br /> KNOLLS , UT 84083 435-384-8915 UTD991301748 <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 /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. 13.Waste Codes <br /> 1. NON RCRA HAZARDOUS TE SOLIDS (DIRT DM P 352 <br /> o , SAND, SOIL, ABSORBENT AND OIL <br /> z 2. <br /> LU <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information "(S(};GM 84632311 LE 15361 <br /> '24H EMERGENCY#800-468--1760—CH/SKfTFI—Cunt rar_t retained by generator confers aggency authori y <br /> on initial transporter to add or substitute additional transporters on enerator's behalf. <br /> 15. GENERATOR'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 and national governmental regulations.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 EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Ge ' Offerors Pri ted/Typed Signature Month D//ay Year <br /> N <br /> J <br /> 16.Intemtional Shipments <br /> ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> Of 17.TransporterAcknowledgment of Receipt of Materials <br /> t—Trans iter 1 Pnnted/T ed Name <br /> OPo )D Signature Month Day Year <br /> CLAAAeiSCaY <br /> 13v �p <br /> Z <br /> Transporter 2 FirintedfTyped Name Signature Month Day Year <br /> 1All <br /> 18.Discrepancy <br /> 18a,Discrepancy Indication Space El <br /> Quantity ❑Type ❑Residue ❑Partial Rejection El Full Rejection.•; <br /> Manifest Reference Number. <br /> 181b.AHemate Facility(or Generator) + <br /> U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Monty Day Y if <br /> a <br /> z <br /> S2 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> D 1 3 Z 2. 3. 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printed Name Sig r Monti 11 e <br /> aj <br /> EPA�nqjj 1?17)E[evious editions are obsolete. ESIGNATED FA LITY TO EPA's e•MANIFEST SYSTEM <br />