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� � ._-� '� � �� -��`�� �`� � - ! illllll lIIIIII(Illlllillllllll 111 l 111 ✓ <br /> SSL SK SHIP# 231101584 <br /> 00744O854sIcs <br /> F ; <br /> Please print or type. I Form Approved.OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1 Gemem"'ID Namter 2.Page 1 or 1 3.Eme en Response Phone 4,ManMast Tracking Number <br /> WASTE MANIFEST CAL000368928 1—�0�-468-176010 I4 4 085 1S'KS J <br /> 5.Generators Name and making Address Genmatota Site Acidness(if different than mating address) <br /> Van Buskirk Golf Course <br /> 1740 Houston Ave <br /> STOCKTON CA 95202-0000 <br /> Gem anne-Phone: 209-470-4114 <br /> 6.Transporter I Company Name U.S.EPA 10 Number <br /> SAFETY--KLEEN SYSTEMS INC TXR000081205 <br /> T.Transporter Company Name U.S.EPA ID Number - <br /> CLEAN HARBORS ENV SVC INC. MAD039322250 <br /> B.Designated Facility Name and Site Address U.S.EPA ID Number <br /> I CLEAN HARBORS GRASSY MOUNTAIN r <br /> 3 MILES EAST, 7 MILES NORTH KNOLLS EXIT 41, OFF I-80 <br /> KNOLLS , UT 84083 s <br /> 435-884-8915 UTD991301748 <br /> Fad' s Phone: <br /> ge 9b.U.S.DOT Description(including Proper Sopping Name,Hazard Class.ID Number, IC.Containers 11.Total 12.Unit 13.Wavle Codas <br /> HM and packing Group III any)) No. Type Quantity WI A'd. a. <br /> M <br /> NONE NON—RCRA HAZARDOUS WASTE, SOLIDS DM P 352 r <br /> o (OIL, DIRT, SAND, ABSORBENTS AND <br /> � 6IESEL FUEL), NAR- <br /> Liu <br /> bULz <br /> w , <br /> 0 rnF, nror cnun nacnonN <br /> �vrr r rr � r <br /> , <br /> 3. <br /> 4. i <br /> 7Y <br /> 14 SpWRHarding lnstructionsand Additional Information TSD:GM 82835532 VA22942 CSG: p, <br /> 24H EMERGENCY#800-468-1760—CH/SK/TFI—Contract retained by gen eratorrc.nfers agency authori y <br /> 15 GENERATOWS1OFFEROR'S CE CATION:I hereby declare that the contents of the ccrosignment are fully and acara'.ely described a ve by the proper ahpp name,and are classified,packaged, <br /> marked and IabeleNplararded,and am in all respects in proper condition for transport according to applicable ntematonal and national governmental regulations.If export shipment and I am de Primary <br /> Exporter,I certify that Ne contents of this consigmnent conform to the,terms of the attached EPA Acim ledgmenl of Consent. <br /> I certify Nat the waste minimization statement identified n 4C CFR 262.27(a)(if I am a Targe quantity ge W)rn(b)(if I e small quantity generates)is true. <br /> Monty Day Year <br /> Ge rdtofslOfferoes rhintedrryped Name tum <br /> a � 3 oro. <br /> J 16.hlemelior!al Shipments ❑Import to U.S. ❑Expo from U.S. Port cf entrYmmt _ <br /> Transporter signature(for exports only): Dale leaving U.S.'. <br /> cc 17.Transporter Acknovrbdgnent of Receipt of Materials <br /> T t Priv Name Signature Monty Day Year <br /> 01L! 3 131 za <br /> Tran gayped Na - - Si Month_ Day Year <br /> /� 3 <br /> 16.Discrepancy <br /> I, 16a.0wepency Indication Space El ouanfit, ❑Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> H i `' <br /> Manifest ReI coce Number <br /> 18b.Alternate Facillty(or Generator) U.S.EPA ID Number t <br /> 1 <br /> � J <br /> Faciitys Phone: <br /> W ik Sot"cfAltemate Facility(or Generator) Monty Day Year <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes lor hazardous waste trea5nent(1t'posal'end recydrg systems) <br /> u, 1 2. 3. A• .,. <br /> 20�For-rn8700-22 <br /> Designated Facility Owner or Operator:Certification of recepl of hazardous materials covered by Ne manifest except as acted m Item 18a Month Day Year <br /> dlTyped Name ' naMe - <br /> L <br /> EPA (Rev 12-17)Prev see ons are obsolete. ESI ATE AGILITY TO EPA's a MANIFEST SYSTEM <br /> 1)8682904/1887822 tie <br />