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SSL SK SHIP# 227710230 111111111111111 III <br /> 0067769555 K5 <br /> Please print or type. Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number CflL000392984 2. 1 <br /> Page 1 of 3. me R e PManifest Tracking Number <br /> 14- <br /> WASTE MANIFEST 006776955 SKS <br /> 5.Generator's Name and Mailin Address Generator's Site Address(if different than mailing address) <br /> O' Reilly # 222 <br /> La <br /> 1200 W throp Rd <br /> MANTECA CA 95338-9870 <br /> Generator's Phone: L09-239-9606 <br /> 6.Trffg rter-1,C,_ritVRi SYSTEMS INC U.S.EPA ID Number TXR000081205 <br /> 7.Transporter 12 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENVIRONMENTAL SVC INC. MAD039322250 <br /> 8.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 /> 408-441-0982 CAD059494310 <br /> Facility's Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing roup(if any)) 13.Waste Codes <br /> No. Type Quantity Wt.Nol. <br /> 1 NON-RCRA HAZARDOUS WASTE, SOLID, DM P 1.81 <br /> 0 (ABSb RBENT AND 0 I L), -448— f <br /> a `-i <br /> UJ <br /> Z 2. <br /> w <br /> C� <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD S SJ 79254846 OR 10542 CSG: <br /> 24H EMERGENCY#800-468-1760-CH/SK/TF1-Contract retained by gI ok Q\3erator confers agency 0 hori Y <br /> on initial transporter to add or substitute additional transporters on nenerator'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 /> 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 Offerors Printed/Typed Name Signature Month Day Year <br /> 16.International Shipments <br /> 0� <br /> K 1:1 Import to U.S. ❑Export rom 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 /> LLJ <br /> 0�—: Tra orter 1 Printed/Typed ame Si Month Day Year <br /> I 1 13 jig <br /> Z Trans �.Int�/Typed Name Si Month Day Year <br /> "N N`� Z t <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space <br /> ❑ Quantity ❑Type ❑Residue <br /> ❑Partial Rejection E]Full Rejection <br /> i <br /> � 18b.Alternate Facility(or Generator) Manifest Reference Number: U.S.EPA ID Number <br /> J <br /> U <br /> W Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 3. <br /> 2 <br /> (�[J 4. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials co by the manifest except as noted in Item 1 <br /> Prin i ed Signatu Month Day Y ar <br /> Ell 0 7L2 s <br /> ';t&,us editionsbloare obsolete.° � , DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br /> x <br />