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SSL SK SHIP#- ^6 W 9 fo k41 q���� <br /> 0063914923 K3 <br /> Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Farm Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number CAL@@@433477 2.Page�a 3.Finer Re P o -706391492 <br /> .ManhatTrTrackin Number <br /> WASTE MANIFEST O O 63�1 4 9 Z SKS <br /> 5.Ge ratofs N me an ailin ddr ss Generator's Site Address(if different than mailing address) <br /> �pee�co <br /> Mm <br /> lube #338 <br /> SR 99 At Jackstone Exit — <br /> RIPON CA 95366—@000 <br /> Generator's Phone: 209-599-7961 <br /> 67r �°P'I SYSTEMS INC U.S.EPA ID Number TXROOO@81205 <br /> 7.T"&VhN o fAM`t5 ENVIRONMENTAL SVC INC. U.S.EPA ID Number MAD0393222513 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE ID Number <br /> 1@21 BERRYESSA ROAD '"` <br /> SAN JOSE , CA 95133 <br /> 4@8-441-@962 CRD059494310 <br /> Facility's Phone: <br /> ge. 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. — , AM P 223 <br /> `r (OIL FILTERS) <br /> Ir U <br /> z 2. <br /> w <br /> O <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Intonation SPE21 7 CSG: <br /> �—1 l bge n <br /> 24H EMERGENCY#800-468-1760—CH/SK/TFI—Contract retained by generatic confers a a ency thori y <br /> on initial transporter to add or substitute additional transporters on generators 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 Iabeledfplacarded,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 EPAAcknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 26227(a)(if I am a large quantity generator)or am a small quanb a is true. <br /> Generators/Offeme,Pnntedrr p d IN Si re Month Day Year <br /> 16.International Shipments <br /> H ❑Import to U.S. ❑Export Pod entry/exit <br /> Z Transporter signature(for exports only): D e leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> K Transpo er 1 Printe yped araeIll. Signature - MonthDay Year <br /> O <br /> IL <br /> QTranspo r2 Pn ecilryped me n Sign u Day r <br /> l / 7 <br /> 18.Discrepancy <br /> Ms.Discrepancy Indication Space ❑Quantity ❑Type ❑Residuej j <br /> El Pallial Rejection Full Re ection <br /> Manifest Reference Number: <br /> 18b.Altemate Facility(or Generator) - U.S.EPA ID Number <br /> J <br /> U <br /> LL Facilitys Phone: <br /> W 18c.Signature of ARemate Facility(or Generator) Month Day Year <br /> Q <br /> Z <br /> 19.Hazardous Waste R ort Man gement Method Codes(Le.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. 3. 4. <br /> 20.Designated Facility r o rator.Certifi Son of reffofira7artious materials covered by the manifest except as m 188 <br /> Pnnledlryped Name \ A E, <br /> Signature n <br /> 1 <br /> EPAFpoy8710 [@3ey. �(lous editions are obs a e. DESIGN FACILITY TO DESTINATION STATE(fiF F I ED) <br />