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SS!- SK SHIP# 229627270 IIIIIIIIIIHIIIIIIIIIIIIIIINIIII III <br /> 0 0 7 1 5 7 0 4 8 S K S <br /> Please print or type. Form Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3.Emelge gR sgr P d.Manifest Tracking Number SKS WASTE MANIFEST CALO@0.,9`c'S84 1 1—t1rOK�— Intl-1 + D 007157048 S KS <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> 01Rei11y # <br /> La3222 <br /> 1200 W throp Rd <br /> MANTECA CA 95336-9670 <br /> Generators Phone: 209-239-9606 <br /> SYSTEMS 1NC U.S.EPA ID Number TXR000061205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAki HARBORS ENV SVC INC. MAD039.322250 <br /> It.Designated Facility Name and Site Address CLEAN HARBORS SAN JOSE U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> SAN JOSE , CA 95133 <br /> CAD059494310 <br /> 408-44i-0962 <br /> Fadlitys Phone'. <br /> pal. 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 ani No. Type Quantity Wt.Nol. <br /> 1 tCNON—RCRA HAZARDOUS WASTE, SOLID, DM P 181 <br /> BE <br /> AND OIL), fKft 6 1 I N b <br /> M z. <br /> W <br /> f7 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Intonation TSD-SJ 81280569 OP10542 CSG: <br /> 24H E1IERGENCY#800-468-1760—CH/SK/TFI—Contract retained by generator roofers agency authori y <br /> on in:,tial transporter to add or substitute additional trans orters on enerator' s <br /> 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 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 EPAAcknowledgment 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 /> GautrslOfferorPd s to yped Name S' Month Day Year <br /> G -�� llw�QeL ►b oa <br /> F 16,International Shipments ❑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.Transporter Acknowledgment of Receipt of Materials <br /> w <br /> � Tr�gsporter t PrintedlFypetl a Signature Mo Day Year <br /> a <br /> YZr Ics, Qtic✓ 1b oI I 1"Ii <br /> QZ Trans orter2 Pnrit, T`yp—ed Name Month Day Year <br /> } llJ TJI IT <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑ I 1:1I <br /> ❑Residue Partial Rejection Full Re ectien <br /> Manifest Reference Number: <br /> 1811 Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> w 18c.Signature of Alternate Facility,(or Generator) Month Day Year <br /> a <br /> z <br /> 05 19.Hazardous Waste Repod Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> G 1. 2. 3. 4. <br /> 20.Designated Facik aloe Certifi on of rete azandous materials covered by the manifest except as noted in U <br /> lPnntedlryped NameSignature M <br /> EPA Form 8700-22((Rev.1 - Pre used nsareosoIete. DESIGNATED FACILITY TO EPA's e-MANIFESTSYSTEM <br /> 1)73612' 7,f 40 559605 <br />