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/ RECEIVED BY SJC EHD (EF) on 4/29/2020 <br /> SSL SHI 2311Qo5. , <br /> Form Approved.OMB No.2050.0039 <br /> Please pent or type. <br /> UN4FORMHAZARDOUS 1.Go..B�orlD 2. 1d 3.em�r,�Resnse one 4ManHastTncMlnpNumber ��� <br /> WASTE MANIFEST 0..800366926 1 1--688-46668="11760nvwasA <br /> 5.GeneraWs Name and Marling Address - Generabls Site Address(8 differem than mailing address) <br /> Van Buskirk Golf Course , <br /> 1740 Houston Ave 95202-0880 <br /> STOCKTON CA <br /> Gene eters Phone: 289-470-4114 <br /> 8 Trac�ta 1 Company Name EMS U.S.EPAID Number I <br /> SAFETY-KLEEN SYSTINC TXR800881205 <br /> 7.Transpoder 2 Company Name U.S.FPA ID Number , <br /> CLEAN HARBORS ENV SVC INC. MAD039322250 <br /> 8.Designated Facdity ameandSi se CLEAN HARBORS OF WILMINGTON U.S.EPA ID Number t <br /> 1737 EAST DENNI STREET <br /> WILMINGTON + CA 90744 CAD044429835 <br /> 310-835-9998 <br /> Fero 's Phone: <br /> 98. 1 9b.U.S.DOT Description(indud"ng Proper Shipping Name,Hazard Gass,ID Number, 10.Conrail 11.Total 12.Unr, 13 Waste Codes <br /> ,fN, and Pacldrtg Group Cd any)) <br /> Na Type Quantity W IWI. <br /> NBME NON RCRA HAZARDOUS WASTE LIQUIDS DM ,,O U P 221 <br /> , (USED OIL WITH WATER), 4IIA,p.4, 7j <br /> F <br /> 2'Nv,U t2CQ*I IQzalcdCX,�WA.�if c L r QuiO-'7 0 <br /> (u ked a;I W�a U)O-PO <br /> 3. <br /> 14 Spatial Handling Instructons and Addaional Informatw TSD:W I 82835532 VA22942 <br /> 24H EMERGENCYOBU-468-1760-CH/SK/TFI-Contract retained by generator confers a ency authori y <br /> 8 13a <br /> 15. GENE TOR'SlOFFE R'S E ICA ON'. hereby declare that the conte-CS of This cormgnmmt are fuYy and acamWy descnbed by the proper sh ppi name,and are dassi packaged. <br /> marked and Iabeledplararded,and are in all respects in proper conditon for transport according to applicahle international and national goverrembil regulations,ti export shipment and I am the Rnmery <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Ackn rMedgment of Consent <br /> I certfy dial the waste minmlzatlon statement identr ied in 40 CFR 262.27(a)(if I am a large quamly,generator on@)(if am a s I quantity generator)is true. <br /> Gener(a�slO1 is Pdntedrrypad Name Sig (; C Month Day Year ) <br /> l �i' LA- r .1 t t <br /> 13 <br /> 16.Interrlebonel SldpmeMs Irl to U.S. ❑Export from U.S` P4 of erdryrexet --- } <br /> Transporter signature(for exports only): <br /> Date leaving U.S.: l <br /> a 17.Transporla Ad5v AeJgment of Receipt of Materials <br /> 5gna Month Day .year <br /> Tris r 1 Pdnledri � ' <br /> Thal0111 <br /> 9Ptid Name Q- Ja`/Signa Monti Day ., <br /> 18.D'rsaepaxy ff��ll <br /> 18a.Discrepancy Indeabon Space u Quarury I J Type LJ Residue IJ Partial Resection ❑Full Rejed'an <br /> Mandest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> LL F.0ty's Phcre: r ! <br /> Q0 8C Sgnature of Alternate Faoil(or Generator) Mordin Day Year - <br /> 2 ` <br /> y19.Hazardous Waste Report Management MedW Cedes(l.e.,codes for hazardas waste trearl disposal,and recycling systems) ; <br /> G 1. 2. ' J 3. 4. <br /> `l <br /> 20.Design Facility Owrer or Operator.CertiBration of rece,pl of hazardous nalanals covered by On man"except as noted in kem 18a <br /> PrjnWypad N / re Month . <br /> a14t 1 <br /> EPA Form 6700-22(Rev.12-1 T)Pfevious editions are obsolete. DESIGNATED FACILITY TO GENERATOR <br /> 1)8833694/2000545 33 C�/��,��C./ i <br />