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SSL SK SHIP# 232275491 11111111111111111111111111 <br /> 0 0 7 7 7 1 2 8 0 S K 3 <br /> Please print or type. Ee poA�e p Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number CAL000392478 2.Pagel of 3.1m—nvrO RVff /60 a Manifest Tracking Number <br /> WASTE MANIFEST 1007771280 SKS <br /> 5.Genemtors Name and Mailing Address Generators Site Address(if different than mailing address) <br /> O' Reilly # 2567 <br /> 1440 E Harding Way <br /> STOCKTON CA 95205-3104 <br /> Generators d aPr�ho�nCep:m v9,72-555-1247 <br /> s.TrJ�HFtI OMDL EVSYSTEMS INC U.S.EPA ID Number TXR008081205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MAD039322250 <br /> 8.Designated Facility Name and Site Address CLEANHARBORS OF BUTTONWILLOW U.S.EPA ID Number <br /> 2500 LOKERN ROAD <br /> BLITTONWILLOW , CA 93206 <br /> 661-762-6200 CAD9B0675276 ' <br /> Faciliys Phone: <br /> qa 9b.U.S.DOT Description(inducting Proper Shipping Name,Hazard Class,ID Number, 10 Containers 11.Total 12.Unit <br /> HM and Padung Crap(if any)) No. Type Quantity W Wol. 13.Waste Codes <br /> NBNE ON—RCRA HAZARDOLISSWW+ASTE, SOLID, l DM P 181 <br /> o (ABSaRBENT AND OIL), <br /> Z 2. <br /> W <br /> U) <br /> 3. <br /> 4. <br /> 14,Special Hardlinglnstruclbns and Additionallnkx don TSD:BL 84087110 DR14384 CSG: <br /> 24H EMERGENCY#800-468-1760—CH/SK/TFI—Contract retained 6y generatorconfers a ency gthori y <br /> on initial transporter to add or substitute additiona s If <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 danded,packaged, <br /> marked and Iabelec/placarded,and are in all respects in proper condition for transport according re applicable intematlmalantl national <br /> govemmemal regulations.de>gtart shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terns of the attached EPAAcknawletlgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(a)IN I am a large quantity generator)a(b)if I am a small quantity generator)is true. <br /> Genera s Frinu:drryped Name Signature Month Day Year <br /> -h'lGv!' lA <br /> J 16.International Shipments <br /> F pod to U.S. ❑Export from U.S. Pon of enhy/e . <br /> ? Transporter signature(for exports only): Dare leaWgU.S.: <br /> K 17.TmnspodaAdmMedgmentoi Rece0of Materials <br /> WTran rrerl Pd rrk.���rrrrrr���nnnSignature Month Da Year <br /> © Y <br /> 2 Transporter 2 NnteNryped Name Signature Month Dab Year <br /> fJ911 O 7-.0 <br /> 4. 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection El Full Rejection <br /> Manifest Reference Number. <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> Faciliys Phone: <br /> a 18c.Signature of Aftemate Facility(or Generator) Month Day Year <br /> 2 <br /> H19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste beatzai disposal,and recycling systems) <br /> p 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 /> N Sig re <br /> i�K <br /> "d tLaga Ekh(th 11iV I <br /> EPAForm8700-22(Rev.12-17 Previouseditionsareobsolete. DESIGNATED FACILITY TO EPA's e-MANIFEST SYSTEM <br /> 1)7361257/405505 G L- D -23 <br /> tie <br />