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SK SHIP# 230426524 1111rilill1 iIIIIIIiIIIIIIIIiIIIIIIII <br /> Please print or t 0 0 7 2 7 5 1 4 3 S K 5 <br /> P type Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number 2.page?of 3. R e P 4.Mandest Tracking Number <br /> CAL000407943 1 '�- -1''��a 1007275143 SKS <br /> WASTE MANIFEST <br /> 5 Generator's Name and Mailing Address Generator's Site Address(if different than mailing address( <br /> King Island Marina <br /> 11530 W Eight Mile Rd <br /> rTOCKTON CA 95219-870". <br /> GeneraWs Phone: 2139-477-5364 <br /> 6 TrF,?"4,CartparncNalne 5YSIFMS INC US EPA ID Number TYr00O08120`' <br /> 7 Transporter 2 Company <br /> N��am�Je�J U.S EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MAD039322250 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE U.S EPA ID Number <br /> 1021 BF_RRYESSA ROAD <br /> SAN JOSE , CA 95133 <br /> 408-441-0962 CAD059494310 <br /> Fadktys Phone: <br /> ga 9b U.S.DOT Description(indudrrg Proper Shipping Name,Hazard Class,ID Number. 10 Containers 11 Total 12 Unit 13 Waste Codes <br /> HM and Packing Group(if any)) No. Type Quantity Wt.Nol. <br /> ' pIW�E NON RCRA HAZARDOUS WASTE SOLIDS, �i 20O <br /> O t, PP�PPFNIITS CONTAMINATED (WITH OIL), Ala — <br /> w <br /> Z <br /> UJ <br /> O <br /> 3 <br /> 4 <br /> 14.Special Kwding Instructions and Additiatel Information TSD:SJ 82116622 K I 18407 CSG <br /> ?4N FMr PSFMIrV#POO-468-1760-CH/SK/TFI-Contract retained by gAo+-Cl� "Ffps a envy author: <br /> art r t d o t ti r s n nera r' t. <br /> 15 fGENERATOR'SIOFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeledrplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations If export shipment and I am the Primary <br /> Exporter,I certily that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I certily that the waste minimizatign statement identified in 40 CFR 262.27(a)(it I am a large quantity generator)or(b)(if I am a small.quantlty generator)is true. <br /> GeneraWs101feroes Prin Signature Month Day Year <br /> 2Z ZO <br /> 116 International Shipmen <br /> Import to U.S Export from US Porto en iexn <br /> ? Transporter signature(for exports only) Date leaving U.S. <br /> Y <br /> 117. er Acknowledgment of Recei I of MaterialsUjPned!Typed Name Signature Month Day Year <br /> O <br /> a <br /> Z Transporter 2 Printed typed Name Signat re Month Day Year <br /> I Zy 10 <br /> 18.Discrepancy <br /> 18a.Discrepancy IrdKabon Space ❑ Quantity, ❑T;,e ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number <br /> 18b.Alternate Facility(or Generator) U S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone. <br /> W t ac Signature of Ahemate Facility(or Generator) Month Da} Year <br /> a <br /> z <br /> y <br /> 19 Hazardous Waste.R4orVAainagqwt Method Codes(i.e..codes for hazardous waste treatment,disposal,and recycling systems) <br /> or 2 3. 4. <br /> 20.Designated Facdity Owner or aN Certifica n of reiep hazardous materials covered by the manifest excep't4 nae 18a <br /> Pnnted/Typed Name Signature Year <br /> WMA Lakt/,�- I —A, <br /> EPA F)7 8700.22(Rev.'2- revious edition ete DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br /> 1 621.31ri/°' <br />