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SSL SK SHIP# 232758482 IIINIIIIIIIIIIIIIIIIII IIII III <br /> 0077719046 K6 <br /> Please print or type. Form Approved.OMB No,2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number umber <br /> 2.Page 1 of 3. m e 4.Manifestiracki11904 <br /> N <br /> GALO@0288559 1 0077 <br /> `�19 0 4 SKS <br /> WASTE MANIFEST <br /> 6. r lots Name and <br /> fit1 DZ aing GeneraKSAd d#'eren�n8rtiling address) <br /> dtOne # 3 9 ozone <br /> 123 Sorath Front Street 1300 W Kettlevan Ln <br /> MEMPHIS Thi 38103-0000 <br /> Generatcu's Phone: <br /> x09 339-4/+5° LGtDI CA 95242-4571 <br /> SYSTEMS INC U.S.EPA ID Number TXR000081 05 <br /> 7.Transporter 2 Com ARMS <br /> U.S.EPA ID Number <br /> GLEAN HRyBORS ENV SVC INC. MAD039322^x50 <br /> 8.Designated Facility Name and Site Address CLEAN HARBORS ARAGONITE, LLC U.S.EPA ID Number <br /> 11600 !NORTH APTUS ROAD <br /> ARAGONITE , CET 84029 <br /> 435-884-8100 UTD981552177 <br /> Facility's Phone; <br /> ge_ 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Cl—,ID Number, 10.Containers 11.Total 12.Unit 13.Waste Codes <br /> HM and Packing Group(dany)) No. Type Quantity Wt.Nol' <br /> X 1- RD. UN1993, L <br /> WASTE FLAMMABLE LIQUIDS DM d P F401 FOOR F003 <br /> 0 U.S., (XYLENES, BENZENE), 3, PG 11 <br /> J <br /> 0001) f 1700 D001 223 <br /> w <br /> Z 2. <br /> LU <br /> to <br /> 3. <br /> 4, <br /> 14,Specht Handling Instructions and Additional Information TSD-AG 84£41323 AU31468 CSG <br /> 1)ERC,#128 <br /> 24H EMERgNCY#800-468-1760-OH/SK/TFI-Contract retained by generator confers agency authori y <br /> on 'initial transporter to add or substitute additional trans orters on enerat©r'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,add are classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transportaccording to applicable intemationaland rational governmental regulations.If export shipment and I am the Primary <br /> por <br /> Exter,I=that the contents of this consignment conform tote terms of the attached EPAAckrwwI4ment of Consent, <br /> I certify that the waste minimbation 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 /> GeneratofslOfferoes Printecayped Name Signature _. Month D Year <br /> 1K uo/T�8 <br /> 16.International'Shipments <br /> ❑I pod to U.S. ❑Export from U.S. Pat of enhylexd. <br /> ? Transporter signature(for exports only): Data leaving U.S., <br /> w 17. _ sporter Adurowedgment of Receipt of Materials <br /> t2 T er 1 Printed Typed N Signature n�onth Dgy Year <br /> a <br /> V ° [:l L✓i <br /> az <br /> Transporter 2Prin !Typed Name Signature Month Day Year <br /> K <br /> 18,Discrepancy <br /> 18a.Discrepancy Indication Space ❑Quantity F1 Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 181h.Alternate Facility(orGenerator) U.S.EPA ID Number <br /> U <br /> Facility <br /> -s Phone: <br /> W18c.Signature of Alternate Facility(or Generator) <br /> Q Month Day Year <br /> Z <br /> 19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> UJ 1. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18a <br /> Printedfryped Name Signature - Month Day Year <br /> EPi)o! tI�11fL� l177 }7PrQviOus editions are obsolete. DESIGNATED FACILITY TO EPA's e•MANIFEST SYSTEM <br />