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SSL SK SHIP# 230662859 111111111111IIIIl 111111111111111 <br /> 735 <br /> Please print or type. 00Form 1 pr v 0 T S K S <br /> Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number CRL000393335 2.(Vag o 3.Eme{gygiyy R sar Phypgo 4.Manifest iacki Number �/(� <br /> WASTE MANIFEST 11 C1O1O 1/ 1007314507 SKS <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> O'Reilly # 3810 <br /> 1551 W Main St <br /> RIPON CA 95366-3012 <br /> Generator's Phone: 972-555-1640 <br /> S.Trgp;p09ir ompAny.Name SYSTEMS INC U.S.EPA ID Number TXR000081205 <br /> 7.TmnnF? to Comlppanny�N�.N S. A u r <br /> e.Design a ityName and site Address CLEAN HARBORS SAN JOSE U.S.EPA ID Nu lber <br /> 1021 BERRYESSA ROAD <br /> Facility's Phone: SAN JOSE , CA 95133 <br /> 408-441-0962 CRD059494310 <br /> 9a 9b.U.S.OOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit <br /> HM and Packing Group(if any)) No. TY9y Quantity Wt.Nol. 13.Waste Codes <br /> —RCRA HAZARDOUS WASTE, SOLID, DM P 181 <br /> of BS�lRBENT AND OIL), <br /> M 01 14t <br /> W <br /> Y� <br /> 3, <br /> 4. <br /> 14.Special Handling Instructions and Additional Information TSD:GJ 82338611 OR12254 CSG: <br /> 24H EMERGENCY#800-468-1760-CH/SK/TFI—Contract retaiC <br /> by generatlip CSW <br /> authori y <br /> on initial ransparter to add or substitute beh <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 classified,packaged, <br /> marked and labeledlplacarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations.R export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the teems of the attached EPA Acknowledgment of Consent. <br /> I certlty that the waste minimization 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 We. <br /> Generators/Offerors Printed/Typed Nam ;k�� Signature Month Day Year <br /> �s �� _ <br /> J 16.International Shipments <br /> F ❑Import to U.S. ❑Export from U.S. Port of entry/exit <br /> ? Transporter signature(for exports only): Date leaving U.S.: <br /> W 17.Transporter Acknowledgment of Receipt of Materials <br /> Tran rtert Pfedi pad me Signal Month Day Year <br /> r(An tom. � 10';L 1 10 1aq <br /> QTransporter 2 Print /Fyped Name Signature Month Day Year <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type <br /> ❑Residue ❑Partial Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J_ <br /> V <br /> rai Facility's Phone: <br /> w 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> a <br /> z <br /> y19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 2, 3. 4. <br /> 29.Designated Facility Ownerg Operator:Certification of receipt of hazardous aterials covered by the manifest except as n in Item 18a <br /> yll PrintedlFypetl Na��RR ��p� Signature Mi y <br /> EP137361257I4055%e�useditions are obsolete. DESIGN FA TO se-MANIFEST SYSTEM <br />