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613L SK SHIP# 232963631 <br /> 0 0 7 7 6 S 8 7 2 S K S <br /> Please print or type. Form Approved,OMB No.2050-OC39 <br /> UNIFORM HAZARDDU5 1:Generator hD Number CAD98167B7�b 3 2.Pageil of 3. rn �R S�e a 4.Manifest Tracking Number'] SKS <br /> WASTE MANIFEST O O 1 6 8$ f V[1S <br /> 5.Ogp.itfock mnoand�Aa�i gAdd s CorpYard Generator's Site Address(if differentthan malting address) <br /> tt 11.. . <br /> 1465 S Lil n St <br /> STOCKTON CA 95206-1.941 ,. <br /> Genoraer's Phone 209-937--8731 <br /> s.TrWffcM&N SYSTEMS INC u-S.EPA ID Number TX R000081 05 <br /> 7.T nsparter 2 Com an Name U.S.EPA IQ Number <br /> GLEAN aNWB5R5 ENV SVC INC. MAD039322250 <br /> 8.Designated Facility Name and Site Address CLEANHARBORS OF BUTTSNW I LLOW U.S,EPA ID Number <br /> 2500 LOKERN ROAD <br /> BUTTONWILLOW , Cly 93 <br /> CAD980675276 <br /> 661-762--6200 <br /> Facility's Phone: <br /> ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Cfass.ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No, Type Quantity wt.Nol. 13.Waste Codes <br /> X 1.=:NA3077 HAZARDOUS WASTE, SOLID, N.O.S. 17M P DOO 181 <br /> O , (CHRLIMIUM), 9, PG III f <br /> 2.449NE— NON-RCRA HAZARDOUS WASTE, SOLIDS DM P 352 <br /> U , (OILY DEBRIS), 1`0ft- — <br /> �� i <br /> 4 <br /> 14.Special Handling Instructions and Additional Information TSD:BL 84727406 ST371 c9 l: <br /> f 1)ERG#171• UAV <br /> 24H EMERGENCY#800-468--1760--CH/5K/TFI-Contract retained by generat❑r confers aenvy authority <br /> on initial transporter to add or substitute additional transporters on eneravor' s behalf. <br /> 15. GEN ERATOR'SIQFFERCR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately desuibed above by the proper shipping name,and are classified,packaged, <br /> marked and labeledlplacarded,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 /> _1qi`rfer,I certify that the contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I ceffify That the waste minimizabDn statement Identified in 40 CFR 261(if I am a large quantity generator)or(b)if I am a small quantity generator)is true. <br /> Gen s Printeciffyipei Signature Month Day <br /> Yennar <br /> U <br /> 15 Interna ional5hipmenls Import to U.S. ❑Export from U.S. Port of en <br /> ture <br /> 'r <br /> ? Transporter signa (for exports only), Date I S.: <br /> K 17-TransporiAcknowledgmantofReceipt ofMaterials <br /> tit <br /> W T ns iter 1 Pnnte ed Name Signakur on h Day Year <br /> CL UG ld�o <br /> Z Transporte 2 Printedffyped Name Slgna re Month Day Year <br /> Q <br /> F- t <br /> 18.Discrepancy <br /> 18a-Discrepancy Indication Space ❑ Quantity ❑Type Residue Partial Re}ection FuRejection <br /> Manifest Reference Number: <br /> 18b.Atkemata Facility(or Generator) US EPA ID Number <br /> v <br /> Faci[ity's Phone. <br /> W 18c-Signature of Alternate Facility(or Generator) Month Day Year <br /> I � <br /> 19.Hazaiddus Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 0 1. / 2. Jf oF 3 4. <br /> 20.Designay F dity Owner or operator:Certification of receipt of hazardous materials covered by the manifest except as Poled in Item 18a <br /> P6nledlT e a e Signature — Ian <br /> € <br /> El Fply {'x ,31°c)e{� ffo5/l1�`�9tGE�1�8` DESIGNATED FACILITY To EPNs e=MAtJIFESI G'r'ti;'111 <br />