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SK SHIP# 234634137 lII��III �IIIIIIIII <br />_ Y�1C) � 008027dZQSKS <br /> Please pent or type 1 :;W Form Approved DMB No 2050-0039 <br /> UNIFORM HAZARDOUS 1 Generator ID Number AL00th32„90;1 2 Pag 1 of 3.€m�y se I'M.i Manifest <br /> 4. Tracking Number WASTE MANIFEST 1008027620 SKS <br /> 5 lots Name and rung Address� s SkAddrees(9ditwt than rnailr addressGO-nstate l quipinent unstate Equi went <br /> 5552 E. Washington St. Atte: Annie 8odeil 75 E Equipment Ct <br /> PHOENIX A7 85034--0000 <br /> GeneratarsPhone 209-443-1682 i FRENCH CAMP, CA 95 3 i. .'Oelo <br /> I Tr@r r?YD_. _ SYSTEMS INC US EPA IONumber TXR300061205 <br /> 7 TranspoVA 2 Com n Name U.S.EPA 10 Number <br /> CLEAN Hi�RT9C1R5 ENV 5VC INC. igAD8393�'cr~:�kr <br /> B Designaled Facility Name and Site Address CLEAN HARBORS ENVIRONMENTAL SERVICES, IN u s EPA ID Number <br /> 22247 S HIGHWAY 71 <br /> KIMBALL , NE 69145 <br /> NED981723513 <br /> ;08-235-401 <br /> Facile 's Phone <br /> ga 9b U S.DOT DesaipbDn(mrludirtg Proper Shrppirg Name,Hazard Class.10 Number. to.Contattiars 11 Total 12-Unit <br /> HM and Packrng Group(if any)1 No. Type Quantity wt" 13.Waste Codes <br /> X 1, UN 1268, WASTE PETROLEUM DISTILLATES, DM ,,{{ P €001 D008 D'b-i <br /> a N.O.S. , 3, PG II <br /> 21V <br /> Z 2. <br /> .tn.t <br /> V <br /> 3 <br /> 4. <br /> td.Special Handling Instructions and Additional Information TSD:KP 86257551 SU31046 C86 <br /> 1)ERt7O�C8' � <br /> 34H EC4lERG <br /> aa�NCY#8017-468-1760-CH/SK/TFI-Contract retained by generatar c n t a ,gency authority <br /> on initial transporter to add or substitute additionai transporters on seer ter ' r1e� 1 f. <br /> 15. QMRATort'SWFEROR's CERT11111CATIDN: t hereby oadane that the oonwft d ft coragrwnwit are fully and ammdely des~above by Im proper semping name.ard are dasadled.packaged. <br /> marked and laheledlplatx dad,and are in all respects in proper condition for transport according to applrcahle mlennA aI and national govemmarAd reguiatbnrptx]enHs.If export shA I SM the Primary <br /> Exporter,i certify that the oaments of thrs corsrgnment conform to the terms of the attached EPAAckndwledg hent sent <br /> 1 rsrofy Ihat the waste mrn�mrzamn staternenl rdel111fiad m 4p CFFt 262 2T(a)Id i am a large quardity generaS7ri d I m a small query gerterslorf to trine. <br /> GeneratarslOflaro>s PnntedlTyped Name Signa Monty Day Year <br /> i-' a 2 <br /> sb atonal Shipments ❑ �rt from . . Port of entry+exit import l0 U.S. - <br /> Transporter signature(for exports only): Date leaving U S. <br /> '7 TrafapprkrAanuw edywg df R"pt of W*rtals <br /> Tra {�rtarr,l PnnledlTyped Name��►nn Sgn t Month 3Daayy Year <br /> te aA 46gY, <br /> rain Month Dav Year <br /> Z r?prnted'1ypeL Name 5 ria re <br /> LJ <br /> Rill biSCrep.iriC r <br /> t8a.Discrepancy tndiwfion Spaces quantity ❑Type L.J Residue PatM Rejection Ll Full Raja.. <br /> Manifest Relerence Number <br /> 16b.Altemale Facility(or Generator U.S.EPA 10 Number <br /> J <br /> U <br /> � Facility's Phone Month Oa <br /> w 182 Swalure of A1Dema a Fadkly{or Generators y <br /> YMF- <br /> a <br /> x <br /> 19 Hazardous Waste Repor!Management Method Codes(i.e..codes for hazardous waste treatment,disposal,and reeydling systems) <br /> C <br /> 2l] Designated Faolly Owner or Operator CerAcation of receipt of haTardDUs materials covered by the manifest except aspaq Item 163 <br /> Pdn amsOF SMonth Day ±Ye�arJ <br /> O7 <br /> El tFon1I7k � Y J317CV]rErB &s loons are obsolete DESIGNATE FACILITY T4 EPA`5 e•MANIFEST SYSTEM <br />