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SSL SK SHIP# 226768747 IIIIII111IIIIIIIIINIIIIi11INIII <br /> Please print or type. O O B B 6 6 7 ;i 2 5 K 5 <br /> Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS t Generator ID Number 2.Pae 1 of 3. m R e P 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000433477 9 1 1 — ��- 0 O O^ 86732 �� <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Speedco Truck Lube #338 <br /> SR 99 At Jackstone Exit — <br /> RIPON CA 95366-0000 <br /> Generator's Phone: 209-599-7%1 <br /> 6.Tr9 yil�W" . . <br /> SYSTEMS INC U.S.EPA ID Number <br /> 1 CtN T7(R000081205 <br /> 7.Transporter2 Com F�BDRn Name <br /> CLEAN HFlS ENVIRONMENTAL SVC INC. US.EPAIDNum7r <br /> MAD039322250 <br /> a.Designated Facility Name and She Address CLEAN HARBORS SAN JOSE U.S.EPA ID Number <br /> 1021 SERRYESSA ROAD <br /> 408-441-0962 SAN JOSE , CA 95133 <br /> Facility's Phone: CAD059494310 <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers <br /> HM and Packing Group(if any)) 11.Total 12.Unit 13.Waste Codes <br /> 1. <br /> No. Type Quantity WUvol. <br /> 0 <br /> O , <br /> w <br /> z z. NON—RCRA HAZARDOUS WASTE, SOLID DM P 223 <br /> � COIL FILTERS) f I <br /> 4. <br /> 14.Special Handling instructions and Additional Information TSD:SJ 78090511 SP22107 <br /> ` CSG: <br /> 24H EMERGENCY#800-468-1760—CH/SK/TFI—Contract retained b 4f 198 <br /> Lon initial transporter to add or substitute additional transnorters onn enera oris authorl Y <br /> 15. GENER.ATOR'SIOFFERGR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above bythe proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper con ion 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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantty generator)or(b)(i1I am a small quantity generator)is true. <br /> Generafarsloff hers PnntedlTyped ame Signature <br /> Month—0.yYear <br /> IS.lntemational hip is <br /> F- Import to U.S. ❑Export from U.S. P of entrylexit: <br /> i Transporter signature(for exports only): - <br /> Date leaving U.S.: <br /> � 17.Transporter Acknowledgment of Receipt of Materials <br /> Tr sporter 1 Prinledliype Name Signalu <br /> a0 ,` ( Month DayYear <br /> z Tamm 2 Pr mew I yped Name lb1,211 ' <br /> ature Month Day Year <br /> ,, � >e -2 J; <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑Quantity ❑ <br /> Type ❑Resitlue ❑Partial Rejecton ❑Full Rejection <br /> F 18b.Alternate Facility(or Generator) <br /> Manifest Reference Number <br /> :3 U.S.EPA ID Number <br /> U <br /> ua- Facility's Phone. <br /> C3 1Sc Signature of Alternate Faolity(or Generator} <br /> Q Month Day Year <br /> z <br /> 19.Hazardous Waste Repel Management Method Codes(Le,,codes <br /> sffor <br /> �rhhhaazaarrddous waste treatment,disposal,and recycling systems) <br /> 0 1 2 3. <br /> 4. <br /> 20.Designated Facility Ow r o erutoc Certifica o of rewi f dazallous materials covered by the manifest except as ride Ba <br /> PrintedlTyped Name Q Signature <br /> aY r <br /> EPA 0- R v. - vios�ejtois eohssle�t777 DESIGNATED FACILITY TO EPA's e- T SYSTEM <br />