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SSL SK SHIP# 231781017 1111111111111 IIIIIIII IIIII IIII <br /> D D <br /> Please print or type. ah^—Tvn3't Form Approved.OMB No 205 <br /> 0-0039 <br /> 1.Generadr ID Number 2.Page!of 3. meryy�Qppyyyy RVg�oge Ph 4.Manifest Tracking Number <br /> UNIFORM HAZARDOUS CAL000393335 1 —tlf410-4b8-1/b01007439753 SKS S <br /> WASTE MANIFEST �71� <br /> 5.Generator's Name and Mailing Address Generators Site Address(d different than mailing address) <br /> O' Reilly # 3810 <br /> 1551 W Main St <br /> RIPON CA 95366-3012 <br /> Generators Phone: 972-555-1640 <br /> 6.Tr9rTYLE1r9 SYSTEMS INC U.S.EPA ID Number TXR000081205 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> CLEAN HARBORS ENV SVC INC. MAD039322250 <br /> B.Designated Facility Name and Site Address CLEAN HARBORS ENVIRONMENTAL SERVICES, IN U.S.EPA ID Number <br /> 2247 S HIGHWAY 71 <br /> KIMBALL , NE 69145 <br /> NED981723513 <br /> 308-235-4012 <br /> Facilitys Phare: <br /> ger 91b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Contairrers 11.Total 12.Unit 13.Waste Codes <br /> HM and Pecking Group if any)) No. Type Quantity Wt.Aml. <br /> X 1. UN3082 WASTE ENVIRONMENTALLY HAZARDOU DM P D02 223 <br /> o S SUBSTANCES, LIQUID N.O.S. MIXTURE, <br /> (CHLORDANE), 9, PG III <br /> z 2. <br /> W <br /> C% <br /> 4 <br /> 14.Spedal Handling Instructions and Additional Information TSD:KP 83600993 OR12254 O�CSG'. <br /> 1)ERG#171• <br /> 24H EMER6�NCY#800-468-1760—CH/SK/TFI—Contract retained byon initial tran%pnrtpr to add or suthstitlits, arletitinn generat tor confers a enc, authori y <br /> on npnpra tarts hhl <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are NIty and a=mtely described above by the proper shipping name,and are classified,packaged, <br /> marked and Iabeledlplacarded,and are in all respeds in proper condition for transport according to applicable international and national govemme I regulations.If export shipment and I am Me Primary <br /> Exporter,I certify that Me contents of this consignment conform to the terms of the attached EPAAcknowledgment of Consent. <br /> I ceMy that the waste minimization statement identified in 40 CFR 262.27(a)(d I am a large quantity generator)or(b)('dl il a small gen tor)is w <br /> GeneradrsrOBemrs Pdnted(ryme Signature <br /> ped Monts Day Year <br /> fe �L 04 a1 <br /> J 16.IntemationsiShipments - <br /> ❑Import to U.S. ❑Export horn U.S. Port leen exn. <br /> i Transporter signature(for exports only): Date lea U.S.. <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> T ponesray r 1 Pn'ntedrr Name Si Month Day gYe_ar <br /> a ICS 1;ls <br /> QTrani2 Printed/Typed Nam nature Monts Day Veer <br /> .Dein e✓ r <br /> 18 Discrepancy <br /> 18a.Discrepancy Indication Space ElQuantity ❑Type ❑Residue ❑Partial Rejection Ll Full Rejection <br /> Manifest Reference Number: <br /> 181b.Alternate Facility(a Generates) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facility's Phone: <br /> w 18c.Signature of Altemate Facility(a Generator) Month Day Year <br /> Q <br /> Z <br /> H19.Hazardous Waste Repot Management Method Codes(i.e.,codes for hazardous waste treatment disposal,and reading systems) <br /> E( <br /> 1' 2, 3- 4. <br /> 20.Designated Facility Owner a Operator Cauficati&�Iptazadasmaterials covered by Me manifest except as noted in Item 18a <br /> PrintedRyped Na�m�e Signature Month Day <br /> 167 111 1 <br /> k EPi;887 (R% 31�004tous ditions are obsolete. DESIG TED FACILITY TO EPA's e-MANIFEST SYSTEM <br />