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SSL SK-SHIP# X9811339 <br /> Please print or type _;1.:.-. ,, Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3. me a Res rise Phle 4.Manifest Tracking Number <br /> WASTE MANIFEST <br /> CAL000429472 I - -4�8-1�se 007313353 SKS <br /> 5.Generators Name and Mailing Address Generators Site Address(if different than mailing address) <br /> O'Reilly N 3811 <br /> 1950 McHenry Ave <br /> ESCALON CA 95320-2081 <br /> Generators Phone: 21x9-838-6364 <br /> 6.Tmns�on 1Comany Name U.S.EPA ID Number TXR00006I205 <br /> SF�ETY—�tLEEN SYSTEMS INC <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 CLEAN HARBORS SAN JOSE U.S.EPA ID Number <br /> 1021 BERRYESSA ROAD <br /> SAN ,LOSE , CA 95133 CAM9494310 <br /> 408-441-09b2 <br /> Fau7ity's Phone: <br /> 9a. 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,0 Number, 10.Comm 't- 11.Total 12.Unit 13.Waste Codes <br /> HType M and Pagkmg Group if any)) No. Quantity WING. <br /> NON—RCRA HAZARDOUS ATE, SOLIDI DM P 181 <br /> o (ABSORBENT AND OIL), <br /> z 2 _ <br /> w <br /> c� <br /> 3. <br /> 4 <br /> 14.Special Handling Instructions and Additional Information TSD:S1 81467233 ORI&56 Mfast <br /> f C <br /> 24H EMERSENCYf800-468-1760-CHISK/TE' I-Contract retained by generatb�CQ cy authori y <br /> an initial transporter to 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that he contents of his consignment are fully and accurately described above by he proper shipping name,and am classified,packaged, <br /> marked and Iabelediplacarded,and am in all respects in proper condition fa transport according to applicable international and national governmental regulations.If export shipment and I am the Pdmary <br /> Exporter,I cedify that the contents of this consignment conform to he arms of the attached EPA Acknowledgment of Consent <br /> If <br /> I certify that the waste minimization statement identified m 40 CFR 262.2,7(a)(g I am a large quantitygeriemtor)a(b)(gl am a small quantity generator)is bue, <br /> Genemtor s Printed/Typed Na Sgnature _ MwM Day Year <br /> J 9 <br /> 6.Intemafiaial Shlpmen 1:1Import to U.S. ❑Export from U.S. Port of entry/exit <br /> Z <br /> �... Transporter signature(for exports only): Date:leaving U.S.: <br /> W 17.TmnsporWAcknowledgmentof ReceiptofMaterials <br /> Tm spotter 1 Pdnted/iyea Name re Month Day Year <br /> a t <br /> aT pone /Typed Name ure Month Day Ye�arj <br /> 18.Discrepancy <br /> 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Pamal Rejection ❑Full Rejection <br /> Manifest Reference Number: <br /> 18b.Alternate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> U <br /> LL Facf s Phone: <br /> W 18c.Signature of Ntemate Facility(or Generator) Month Day Year <br /> Q <br /> z <br /> w19.HaZdNOUs Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1 2. 3. a. <br /> 20.Designated Facility Owner or Operator:Certification of receipt of hazardous materials covered by the man est t as noted in Item 18a <br /> Printed tl Name YTk Signatu Mon Day.Day Year <br /> Wk <br /> Iq <br /> EPA Form 8700-22 Rev.12-17 Prev ous editions am obsolete. DESIG ACILITY TO GENERATOR <br /> 1)7351257/405 <br />