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SSL SK SHIP# 231101570 1111111111 <br /> 0074408503 K5 <br /> Please print or type. Form Approved.OMB No.2650-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2 Page 1 of 3.Emer a Response Phone 4.Man fest Tracking Number <br /> WASTE MANIFEST CAL000368928 1 1- 0�-468-1760 K$ <br /> $ <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) SKS <br /> V <br /> Van Buskirk Golf Course <br /> 1740 Houston Ave <br /> STOCKTON CA 95202-0000 <br /> Generators Phone: 209-470-4114 <br /> 6.Trans orter 1 Com any Name U.S.EPA ID Number <br /> SIF�FETY—(LEEN SYSTEMS INC TXR000081205 <br /> 7 Transporter 2 Company Name US EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MAD039322250 <br /> 8.Designated Facility Name and Site Address CLEANHARBORS OF BUTTONW I LLOW U.S.EPA ID Number <br /> 2500 LOKERN ROAD <br /> Facility's Phone: BUTTONWILLOW , CA 93206 <br /> 661-762-6200 CAD980675276 <br /> ga 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Umt <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Noi 13.Waste Codes <br /> cr 1. NtW NON RCRA HAZARDOUS WASTE LIQUIDS BW ;60 P 291 <br /> o , (LhTEX PAINTS), 0,� <br /> Uj f. <br /> W 2 NO NON—RCRA HAZARDOUS WASTE, P t*#4 <br /> LIQUIDS, (MIZER), N-FA �00 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:BL 82835532 VA22942 <br /> 24H EMERGENCY#880-468-1760—CH/SK/TFI—Contract retained by generator confers aency authori y <br /> nn initial '15. GENERATOR'SIOFFEROR'S CE FtCATION: I hereby declare that the contents of this consignment are fully and accurately described a ve by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and natioral 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 EPAAcknewlerdgm t of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quantity general o (b)(if I am a s(Uluantity generator)is true. <br /> XsJCfferor s Printed/Typed Name Si na Month Day Year <br /> (�lA2oLyr.) Cr�o,� in �.✓��� -3 131 020 <br /> J 16.Mernatonal Shipments <br /> &-- ❑Import to U.S. ❑Export from U.S. Pon o ntrylexiC <br /> ? Transporter signature(for exports only). Date leaving U.S.: <br /> 2 17.Transporter Acknowledgment of Receipt of Materials <br /> w <br /> � Tran r 1 Prinled/Typ Name Signature Month Day Year <br /> a w� .3 3 �� <br /> V) Transporter 2 Prin dfTyped Name Signature Month Day Year <br /> It- Lie—s lin, A114AMa z <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space <br /> t3.L W�+w O ❑Type ❑Residue ElPartial Rejectan ❑Full Rejection <br /> 11+•t. 6�c `er <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> W Facility's Phone: <br /> w 18c.Signature of Altemate Facility(or Generator) Month Day Year <br /> H <br /> Q <br /> z <br /> 19.Hazardous Wasle Report Management Method Codes(i.e codes for hazardous waste treatment,disposal,and recycling systems) <br /> o , 3 <br /> . 1-132 2. P 13Z 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest noted i Item 8a <br /> Printed/Typed Month Day Year <br /> Z <br /> of, do�c.se 0`>� 03 <br /> aa <br /> EPA Form 8700.22(Rev.12-17) Previous editions are obsolete. ESIGNATED FACILITY TO EPA's e•MANIFESTSYSTEM <br /> 1)8829007/2000517 2)8832517/2000702 <br />