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SSL SI( 5HIP1k 231101595 <br /> 11111111111111HIaI�IHlllllll <br /> 0074406525 K3 <br /> Please print or type Form Approved.OMB No.20500039 <br /> UNIFORM HAZARDOUS 1.Generator 10 Number 2.Page 1 of 3 Fm R4.g Phone A.Manifest Tracting lMmMr <br /> WASTE MANIFEST CAL000368928 I 1901760 0 SKS <br /> 5.Generator`* <br /> Name and Maiing Address Generators Sb Address(d Merent than maiing address) <br /> Van Buskirk Golf Course <br /> 1740 Houston Ave <br /> STOCKTON CA 95202-0000 j <br /> Gweralors Phone: 209-470-4114 <br /> 6.Teats rter 1 Com M Name U.S.EPA ID Number <br /> SF�FETY—�(L.EEN SYSTEMS INC TXR000081205 ' <br /> 7.Transporter 2 Company Name U.S.EPA 10 Number <br /> CLEAN HARBORS ENV SVC INC. MAD039322250 <br /> 8.Designated Fadity Name and Sita Adaess CLEAN HARBORS SAN JOSE U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE , CA 95133 <br /> 408-441-0962 CAA059494318 <br /> Fadi s Phone: <br /> 9a. 9b.U.S.DOT DesvgWn(ndudng Prow Shipping Hama,Hazani Class,M Number, 10.Containers 11.Total 12.lid 13.Wash Codes <br /> w and Peckng Group(d any)) No. Type Quantity Wt/Vol. <br /> NOW NOONN)RCRAHAZ RDOUS WASTE LIQUIDS I DM � - P 343 <br /> w <br /> • z 2. <br /> w <br /> c7 <br /> 3 <br /> I <br /> 4. <br /> i <br /> 14.Spedai Handling nsla dl s,and Additional Information TSD:SJ 82835532 VA22942 C 111 <br /> 24H EMERGENCYN800-468-1760—CH/SK/TFI—Contract retained by generator confers a ency authori yl <br /> 15. GENERATORSIOFFEROR'S FICATION:--nn—initial tk-anq -Pr I hereby dedae that he contents of tnis vonsignrnent are Uly and accurately desabe0 abm by the proper ehoirt name,and are dasslW.pedaged. <br /> marked and labeledplacarded,and are in all respects in proper con niton for transport awarding to applicable international and national governmental regulations If export shipment and I am the Primary <br /> Exporter,I certify that be"Lents of this consignment conform to he term of Ne attaded EPA Arknowbdgnent of Comer. <br /> I comfy that the waste mlrimizatim statement Identifled n 40 CFR 26227(a)(N I am a large quantity generab(A(b)(dl am a 1 quantity,generator)6 true. <br /> Gen 6 PnbVll ed Na Month Day Year <br /> x1�� D064 VN 3 3 <br /> 1-1 16.Inhnatbnal SNpmend ❑Import to U.S. ❑Export Iron U S. of entylexit <br /> = Transporter signature(for exports o*): Date Iswig U.S <br /> K 17.Transporter Admowlcdgmert of Remilet of MakerWs <br /> LU <br /> Tra 1 Pdntod/T Signabxe Month Day Year <br /> a V 3 a <br /> T der 2 yped me MmM Day Yea <br /> i CA C, 3 <br /> t18.Discrepancy <br /> 18a.Dkaep—y Indicator Spatz L1y E)Type ❑Residue ❑PaGal n ❑Fdl Rejection <br /> Manifest R.I.—Number <br /> I8b.Alternate Facility(or Generator) U.S.EPA ID Nwbe <br /> J <br /> U <br /> LL Faditys Phone: <br /> w 18c.Slgrt<nbxe ofAlternate FadIly(or Generator) MonthDay Year <br /> Q <br /> z <br /> H19.Hazardous Waste f eport Man e <br /> ennl WOW Codes(i.a.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> Lill 1 2. 3. 4. <br /> 20,Designated Fad' r: 'pt of heladous matertats covered by the mann xcept 188 <br /> Pritedrrypad Name Sig 1 <br /> EPA Fo m 870022(R 17 Plevou di sole e. DESIGNATED FACILITY TO EPA's e-MA94FE,T SYSTEM <br /> 1Y8828995/2000566 <br />