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SSL SK SHIP# 230472700 I1111111�I�'III�I�IIIII�IIIINI�II <br /> Please print or type. 007275199SK3Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS i.Generator ID Number 2.Page 1 of 3.Emer en Res nse Phone 4.Manifest Tracking Number <br /> WASTE MANIFEST CAL000081643 i-6�0�-4�8-1760 007275199 SKS <br /> 5.Generator's Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> Ladds Marina <br /> 4911 Buckley Cove Way Patricia Bonnifield <br /> STOCKTON CA 95219-2025 <br /> Generators Phone: 209-477-9521 <br /> 6.Trans iter 1 Company Name U.S.EPA ID Number <br /> SIFETY-KLEEN SYSTEMS INC TXR000081205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MAD039322250 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS ARAGONITE, LL-C U.S.EPA ID Number <br /> 11600 NORTH APTUS ROAD <br /> ARAGONITE , UT 84029 UTD981552177 <br /> 435-884-8100 <br /> Facility's Phone: <br /> ga 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(if any)) <br /> No. Type Quantity WlNol. <br /> 1' NON RCRA HAZARDOUS WASTE SOLIDS, DM yD P 223 <br /> o (ABSORBENTS CONTAMINATED WITH OIL), -N44 <br /> �a <br /> w <br /> Z 2. <br /> LU <br /> 0 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:AG 82173850 LA28534 C <br /> 24H EMERGENCY#800-468-1760-CH/SK/TFI-Contract retained by generator confers a ency authori y <br /> —.Lln initial t n —"'S CE TIFICATION: I 15. GENEPATOR'S/OFFER9� hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are dassified,packaged, <br /> marked and labeled/placarded,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 certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large erator)or(b)(if I am a small quan'ty generalor)is true. <br /> era s/Off rs r nled(Ty ed Name Month Day Year <br /> a 22 zv <br /> J 16.International Shipments <br /> � ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> w 17.TransporterAcknewledgment of Receipt of Materials <br /> Transp r t d yped N me Signature Month Day Year <br /> O <br /> q-2- Z0 <br /> Z Transpo 2 PrintedrTyped Name Signal a Month Day Year <br /> 9 <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑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 /> ,0 18c.Signature of Alternate Facility(or Generator) MonthDay Year <br /> f— <br /> a <br /> Z <br /> C9 <br /> N 19.Hazardous Waste Report Management Method Codes(i.e codes for hazardous waste treatment,disposal,and recycling systems) <br /> ui <br /> C31 2 3 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Pr nted(Type Name Signature Month Day Year <br /> 2 I2 20 <br /> EPA Form 8700-22(Rev.12-17) Previous editions are obsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br /> 1)7692883/1102001 <br />