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SSL SK SHIP* 231101602 1111111"Anull 1151 <br /> 1111 <br /> 007440853sKs V <br /> Please print or type. Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Gene ator!D Number 2.Page 1 of 3.Emer ency Response Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL@00368928 1-40-468-176@ o y 440853 SKS <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> Van Buskirk Golf Course <br /> 17410 Houston Ave <br /> STOCKTON CA 95202-0@08 <br /> Generators Phone: F_@9-470-4114 <br /> fi Transporter 1 Company Name U.S.EPA ID Number <br /> SAFETY-KLEEN SYSTEMS INC TXR000@81205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MAD839322250 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS ARAGONITE, LLC U.S.EPA ID Number <br /> 11600 NORTH APTUS ROAD <br /> Facility's Phone: ARRGONITE , UT 84829 <br /> 435-884-8180 UTD981552177 <br /> ga, 9b.U.S.DOT Descdptbn(nduding Proper Shipping Name,Hazard Class,ID Number, 10,Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(f any)) No. Type Quantity Wt.Nol. <br /> lour <br /> RCRA HAZARDOUS WASTE, SOLIDS ow P NONE <br /> 'IF.R ILIZER DEBRIS), ItF,4,06 c+2 ,OOJ <br /> 4�0 1 <br /> 2. —1 ace <br /> 0 ES 1 <br /> 3. <br /> 4. <br /> SpedalHandling instructors and Additional Information TSDsA6' 82835532 VA22W C4 6 <br /> 24H ElI�R69ICY*$@ 4fa6=1760-CH/SK/TFI-Contract retained by generator confers a 4ncy author* y <br /> 15. GEHERATOftOFFEROR'S C ICA ;Thereby declare that the contents of this consignment are fully,�Fd assurately described ve by the proper ippl,.name,and are classified,packaged, <br /> marked and labelecilplacarded,and are in all respects in proper condition for transport according to applicable iptemallobal and national governmental regulatior,sAf 4porl shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowl"'bf Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(it I am a large quantity yen or(b)(f t W small quantity generator)is true. <br /> GeneeslDfferorsPrinted ed Name Sign e M Day. Year <br /> �C \Y(3 <br /> 1E.International Shipments_ <br /> ❑Import to U.S. ❑Export from U.S. ort of entrylexit: <br /> Z Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TransporterAcknc%�,dgment of Receipt of alerials= <br /> T s er 1 P ntecL Name Signature Day Year <br /> O 3 p4�/V� <br /> CL <br /> QTr s rtel2 P ted(f ed ame Sign f Mont Day Year <br /> < V { CA <br /> f- <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity 11Type ❑ r Residue 1 l Partia•Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b,Alternate Facility(or Generator) U.S.EPA 10 Number <br /> J <br /> U <br /> tai Facility's Phone: <br /> w 18c.Signature of Nternate Facility(or Generator) Month Day Year <br /> F- <br /> a <br /> Z <br /> y19 Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> w 1. 2. 3 4. <br /> 11 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest except as rated in Item 188 <br /> Pnnted/T N St Nre Month Day Year <br /> -` t WS, I A q o-� <br /> EPA Form 8700-22(Rev.f 2-17) Previous editions are obsolete. DESIGNATED FACILITY TO EP e-MANIFEST SYSTEM <br /> 1)8832528/20@0718 <br />