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5SL SK SHIP# 02 6427668 11111111111111111111111111111111111111 <br /> 0 0 6 3 9 1 7 7 2 S K S <br /> Pease print Qr type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number CPL000207935 2.PaqQof 3.Itme R e P 4.Manifestn Number <br /> ._�� _ _t��01000 1772 SKS <br /> WASTE MANIFEST <br /> 5.Generators Name and Mailing Address Generator's Site Address(if different than mailing address) <br /> AUt ozone # 3326 Autozone # 3-2:6 <br /> 123 South Front Street 2309 W Hammer Ln <br /> MEMPHIS TN 38103 <br /> Generator's Phone: 209-477-9788 STOCKTON CA 95209--2367 <br /> 6.Tr SpoAerlComp y Wawa SYSTEMS INC U.S.EPA ID Number TX R000081 X05 <br /> 7.Transporter 12 C7ComppalltName U.S.EPA ID Number <br /> CLEAN HA4BORS ENVIRONMENTAL SVC INC. MAD039322250 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS ENVIRONMENTAL_ SERVICES, IN U.S.EPA ID Number <br /> 2247 S HIGHWAY 71 <br /> (} KIMBALL. , NE 69145 <br /> 300-235-4016 NED981723513 <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10,Containers11.Total 12.Unit <br /> HM and Packing Group(if any)) No. Type Quantity Wt./Vol. <br /> 13.Waste Codes <br /> Mom NON-RCRA HAZARDOUS WASTE DM CO P 343 <br /> �fo LIQUIDS, (ETHYLENE GLYCOL SOLIA 1 ON), � I <br /> NA�l <br /> LU 2. <br /> LU <br /> C7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:KP � 7757{ir[� �L�� �6F� �n_ <br /> 24H EMERGENCY#800-468-1760-CH/SK/TFI-Contract retained by generator confers. agency artthori y <br /> on initial transporter to add or substitute additional transporters Ongenerator' s behalf. <br /> 15. GENERATOR'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 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 quantity generator)or(b)(if I am a small quantity generator)is true. <br /> Generator'slOfferor's PrintedfTyDe~e Signature Mo th Day Year <br /> J 16.International Shipments <br /> 1- ❑Import to U.S. ❑Export from U.S. Port of entry/exit: <br /> K Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> � Tra o r 1 PrintedlTy me SignatC Month Day Year <br /> CL o l/�Lc 1/6 /9 <br /> CO <br /> QTrans 2 ted Typed Name Signature ` Month Day Year <br /> t- <br /> ley <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 /> Facility's Phone <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> - 11a <br /> z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 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 /> Printedffyped Name Sign re Month DayYe <br /> 1 <br /> EPA Form 8700-22 TRev.3-05 Previous editions are obsolete. IfESIGNAYE-D 0AGILITY TO DESTINATION STATE(IF REQUIRED) <br /> 1)793'2181/1397286 <br />