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SSL SK SHIP# 231266506 1111111111111 oil Ill III <br /> Please print or pe. O ' <br /> tyForm Approved,OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator lD Number CAL000392984 2.Pagel of 1 3.€n—W Iftr O 4.ManHast Tracking Number �/ <br /> WASTE MANIFEST 00747666 SKS <br /> 5.Generator's Name and Mailin Address Generators Site Address(t diterent than mailing address) <br /> O' Reill # 3222 <br /> 1200 W Lathrop Rd <br /> MANTECA CA 95336-9670 <br /> Generators Phone: 209-239-9606 <br /> 6.Tr r1a`It'°—W SYSTEMS INC U.S.EPA ID Number TXR000081205 <br /> 7.Transpoder2Com an Name U.S.EPA ID Number <br /> CLEAN H�1F�HORS ENV 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 , CR 95133 <br /> 408-441-0962 CAD059494310 <br /> Fadl' S Phone: <br /> ger 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM a dPadting Group(ifany)) No, Type Quantity Wt.N01. <br /> 'C - NON—RCRA HAZARDOUS WASTE, SOLID, DM P 181 <br /> o (ABSORBENT AND OIL), 04'A , -3D <br /> Z Z. <br /> W <br /> n9 <br /> 3. <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:SJ 83012451 OR10542 ^ �� � t/y_( <br /> 44 <br /> 24H EMERGENCY#800-468-1760—CH/SK/TFI—Contract retained by generator confers ayBnCy authori y <br /> on initial transporter to add or substitute additional trans orters on enerattor' s behalf. <br /> 15. GENERATOR'SIOFFERDR'S CERTIFICATION: I hereby declare that the contents of this consignment am fully and accurately described above by the proper shipping name,and are classified.pacAeged, <br /> marked and labeleclplaiarded,and are in all re5peds in proper condition for transport according to applicable international and nalionig govemmental regulators.t export shipment and I am the Primary <br /> Exporter,l oe*that the contents of this consignment conform to the terms of the attached EPAAdmowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)(if I am a large quare ity generator)or(b)('dl am a small quantity generator)is We. <br /> 19 <br /> GeneraleslOffsmrs Pdn yped Name Signature Monti Day Year <br /> 1 <br /> 16.Intematonal Shipments <br /> r ❑Import to U.S. ❑Expod from U.S. Pon ofentrylexit: <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.TransporterAdmoMecigment of Receipt of Materials <br /> T reporter i PrintedffyPed No re Month Day Year <br /> aIC <br /> t'1 W74b <br /> Z ransporter 2 Pnnted(fyped Name Month DaY Year <br /> WOKqG 2 <br /> .k 18.Discrepancy <br /> 18a.Discrepancy Indication Space Elons, [--]Type 11 Residue ❑Partial Rejection ❑Full Rejection <br /> Man'dest Reference Number: <br /> 181b.Alternate Fadlity(or Generator) U.S.EPA to Number <br /> J <br /> V <br /> LL Facility's Phone: <br /> W 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> 19.Hazardous Waste Report Management Metrod Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2. 3. 4. <br /> 20,Designated Facility Owner or Operator.Certifi receipt of hazardous mate' s by the manifest ex ce nded in Item tea <br /> S@nWe e <br /> EP1) /361257/�1•ID- 6r�v5tous ditions are ol>Solete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br />